TEMPLATE
Identifying Data: Age, Gender, Occupation, and Marital Status
Source and Reliability:
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – may be a brief summary of reason patient wanted to be seen for this visit
HPI: Complete subjective description of problem, including “OLDCARTS” findings or similar, including location, quality severity, duration, timing, context, modifying factors, associated signs/symptoms, relieving and aggravating factors, related systems.
Medications, including OTC and Herbals Preparation
Past Medical History:
Allergies – medications, food, environmental or seasonal
Childhood Illnesses – Chicken pox, Rheumatic fever, Rubella, Measles, and Mumps
Adult Illnesses
Injuries
Surgeries
Hospitalizations
Obstetric/Gynecologic
Psychiatric
Health Maintenance
Immunization status – DPT, MMR, Influenza, Hepatitis, Polio, and Pneumovax
Dental Exams (frequency and treatment)
Last eye exam (include results)
SBE/Pap/GYN (include results)
Testicular/rectal exam (include results)
Family History: Include presence or absence of specific illnesses in family such as hypertension, diabetes, or cancer
Personal and Social History:
Educational level
Personal interests
Lifestyle – exercise and diet
Older Adults – ADLs and iADLs
Review of Systems: Pertinent positives and negatives in the differential diagnosis
Objective
Vital Signs
Blood Pressure
Temperature
Pulse
Respirations
Height
Weight
BMI including normal, overweight, obese, morbidly obese
Physical Examination – specific systems as appropriate
Assessment and Plan (This section should process for the reader, should be based on current literature/guidelines. This should be organized and succinct.)
Differential diagnoses including ICD – 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings.
Rationale: Articulate a rationale for the most likely diagnosis and for each differential diagnosis. In this discussion, include pertinent positives and pertinent negatives which help to rule out or rule in each diagnosis.
Most likely diagnosis: (if more than one diagnosis, number each in order of priority)
Include:
Pathophysiology of the problem
Explanation of the diagnosis
Diagnostic Testing
Lab testing
Radiology testing
Cardiac or Neurologic testing
Evaluations – Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health Evaluations
Medications and Treatments – pharmacological and non-pharmacological treatments. Should include at least 2 evidenced based references
Motivational Interviewing
References (APA Format)
