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Demographic Data Age, and gender (must be HIPAA compliant) Subjective Chief Complaint (CC) unless an Annual Physical Exam (APE) History of P
Demographic Data * Age, and gender (must be HIPAA compliant) Subjective * Chief Complaint (CC) unless an Annual Physical Exam (APE) * History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment) * Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies,