Name: 

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”

HPI:  Use OLDCART acronym

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med ) write medicine the same way you write a Rx

PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies:  

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

Family History (list immediate family, age, disease, and whether is dead or alive)

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.

Weight        BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)

Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)

 Diagnosis

 Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)

· 1-

· 2-

· 3-

Diagnosis with ICD 10 Code

CPT Code/Office visit code:

Plan/Therapeutics

· Plan: 

· Further testing

· Medication

· Education

· Non-medication treatments

· Follow Up

· Referral

· When to seek emergency care

 Evaluation of patient encounter

Document your level of interaction with the patient.

Weaknesses:

Strengths:

Reflection: