Reference no: EM133833699

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?  Get top-rated assignment assistance now!
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.