• 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,

immunizations, and preventative health maintenance as applicable • Family Hx: As applicable • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap,

vaccines, colonoscopy)

Objective

• Vital signs • Physical findings listed by body systems, not paragraph form

Assessment (Diagnosis/ICD10 Code)

• Include all diagnoses that apply for this visit

Plan

• Dx Plan (lab, x-ray) • Tx Plan: (meds) • Pt. Education, including specific medication teaching points • Referral/Follow-up • Health maintenance (including when screenings, immunizations, etc., are next due):

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