Demographic Data
• Age, and gender (must be HIPAA compliant)
Subjective
• Chief Complaint (CC): A short statement about why they are there
• History of Present Illness (HPI): Write your HPI in paragraph form. Start with the
age, gender, and why they are there (example: 23-year-old female here for…).
Elaborate using the acronym 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
• Family Hx: any history of CA, DM, HTN, MI, CVA?
• 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- Highlight abnormal
findings
Assessment (the diagnosis)
• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent
positives and negatives for each
• Final diagnosis with rationale, pertinent positives and negatives, and
pathophysiological explanation
Plan
• Dx Plan (lab, x-ray)
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency,
duration, and refill(s) (if any)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance: including when screenings eye, dental, pap, vaccines,
immunizations, etc. are next due
Reference
• Compare care given to the patient with the National Standards of Care/National
Guidelines. Cite accordingly.
