Past medical history  current problem

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Reference no: EM133797633

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.  Get solution now!
• 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.
Plan
• Dx Plan (lab, x-ray)
• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points.  
• Safety Plan    
• Referral/Follow-up
*Based on population focus, some additional details may be required by faculty Top of Form

Reference no: EM133797633

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