· Biographic Data:– Age/race/gender, date, occupation, language/communication needs.

· Source – and reliability

· Chief Complaint (reason for seeking care)- make every attempt to use patient’s own words.

· History of Present Illness (HPI)- complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.

· Past Medical History (PMH)- childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, Immunizations, last exam

· Allergies, medication, food, environmental

· Medications– Rx, OTC, herbal, etc.

· Family History– write a genogram diagram or outline; age, health, age, and cause of death of each family member going back three generations.

· Personal and Social History– interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle, alternative health care practices, sexual and obstetric history.

· Review of Systems (ROS)- series of questions from head to toe. Must be in the following order – include health promotion practices:

· General Survey

· Integumentary

· Head, Eyes, Ears, Nose, and Throat

· Neck/thyroid

· Breasts and axillary lymph nodes

· Respiratory

· Cardiovascular

· Peripheral vascular

· Gastrointestinal

· Genitourinary

· Genital/Reproductive system

· Sexual health

· Musculoskeletal

· Neurological (must include reflexes on PE)

· Hematologic

· Endocrine

· Functional assessment – include activities of daily living

· Self-esteem/self-concept

· Activity/exercise

· Sleep/rest/nutrition, include

· Nutritional status assessment- identify if patient is at risk for malnutrition or over nutrition

· Interpersonal relationships

· Spiritual resources

· Coping and stress management

· Personal habits – alcohol, tobacco, street drugs

· Environment/Hazards

· Intimate partner violence

· Occupational health

· Perception of health

· Developmental Competence – children, pregnant women, older adult

Objective data

· Physical Examination (PE)

· General Survey

· Integumentary

· Head, Eyes, Ears, Nose, and Throat

· Neck/thyroid

· Breasts and axillary lymph nodes

· Respiratory

· Cardiovascular

· Peripheral vascular

· Gastrointestinal

· Genitourinary

· Genital/Reproductive system

· Sexual health

· Musculoskeletal

· Neurological (must include reflexes on PE)

· Hematologic

· Endocrine

Assessment

· Diagnosis with rationale

· Differential diagnosis with rationales

Plan

· Dx plan – include diagnostic tests needed (lab, x-ray, etc.)

· Tx plan – include recommended treatment – cite national guidelines

· Patient education – including specific medication teaching

· Referral/Follow up

· Health Maintenance – include health promotion recommendations from AHRQ (ePSS app) according to age/gender/conditions