Review the rubric for more information on how your assignment will be graded. Demographic Data ...
Review the rubric for more information on how your assignment will be graded. Demographic Data 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):
