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Demographic Data
Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective
Chief Complaint (CC)
History of Present Illness (HPI)(symptoms) in paragraph format Past Medical History (PMH):Current problem-focused and document pertinent information only.
Current Medications:
Medication Allergies:
Social History: For current problem-focused and document only pertinent information only.
Family History: For current problem-focused and document only pertinent information only.
Review of Systems (ROS) as appropriate:
Objective
Vital signs
Mental Status Exam Physical findings listed by body systems, not paragraph form. Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal) Assessment (Diagnosis/ICD10 Code) Include all diagnoses that apply to this visit. Include one differential diagnosis.
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