SUBJECTIVE

What the patient (The Subject) says to you during question and answers).

Identification of patient

CC (CC in quotes) – Make one up for your patient

HPI: What happened? What did they try? How long as it been? No more than 3-5 sentences.

PMH: If none provided in question, state 3 relevant questions you would ask your patient for this section.

MEDs: (if any) if no meds, NA

Allergies: If none provided in question, state 3 relevant questions you would ask your patient for this section..

FH: If none provided in question, state 3 relevant questions you would ask your patient for this section.

Social Hx: If none provided in question, state 3 relevant questions you would ask your patient for this section.

Health Related Behaviors: If none provided in question, state 3 relevant questions you would ask your patient for this section.

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Review of Systems (ROS): See Below

Admits or denies to symptoms questions asked TO THE PATIENT by system: (Ask symptoms that could be related to complaint or Risk Factors for this patient – SOME ARE REQUIRED FOR ALL PATIENTS in RED regardless of complaint(s))

YES OR NO, admit or denies to questions asked of patient. NOT PHYSICAL EXAM. (You can add more, not conclusive list)

** Constitutional/General – Lack of energy, feeling unwell, tired,

Ears, Nose, Mouth & Throat – Difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness.

** Cardiac – Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking.

** Respiratory – Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, coughing up blood.

GI – Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence.

GU – Painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence.

Musculoskeletal – Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain.

Dermatologic – Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes.  Other:

Neurologic – Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss.

** Psychiatric – Insomnia, irritability, depression, anxiety, suicidal, homicidal, hearing voices or seeing items that others don’t see, paranoia.

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OBJECTIVE

Observed, noticed, or found on exam

RED Required

This section documents the objective data from the patient encounter. This includes:

• Vital signs – if given in question.
• Physical exam findings ** See Below
• Laboratory results only
• Imaging results only
• Other diagnostic data – old information reviewed
• Recognition and review of the documentation of other clinicians.

 Physical Exam (not ROS)

ONLY RELATED TO COMPLAINT THAT YOU CHECKED – RED REQUIRED

(Listed below are Within Normal sample findings – change at will)

General: Awake, alert and oriented to time, person, place, and situation. No acute distress. Well developed, hydrated and nourished. Appears stated age. Patient appropriately dressed for event.

Skin: Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing.

Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

Eyes:  Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOM are intact, PERRLA. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.

Ears: External ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice.

Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.

Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates.

Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. Carotid pulse 2+ bilaterally without bruit. No JVD.

Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity. No S3 or S4 heard.

Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields.

Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.

Genital/Rectal (If applicable or annual physical): Normal rectal sphincter tone. No external masses or lesions. Stool is normal in appearance. guac negative. External genitalia normal in appearance without lesions, swelling, masses or tenderness. Vagina is pink and moist without lesions or discharge. Cervix is non-tender without lesions or erosions. Uterus is anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or enlargement.

Spine: Neck and back are without deformity, external skin changes, or signs of trauma. Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits.

Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. Steady gait noted.

Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are grossly intact CN 1-12. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.

Psychiatric: Appropriate mood and affect noted. Good judgement and insight. No suicidal or homicidal ideation.

Assessment – Diagnose and Justify

MAIN GRADED AREA BELOW – FOCUSED HERE THIS TERM

REFERENCE EVERYTHING!!!

YOU HAVE TO USE REFERENCES for this section – PLEASE CHECK ICD10data.com to make sure you have a billable diagnosis.

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1. REQUIRED – Working diagnosis with Pertinent positive and negatives – REFERENCED – Where did you get this information from? Scholarly only.

Pertinent Positive with reference (LIST)

Pertinent Negative with reference (LIST)

 

1. REQUIRED – Differential Diagnosis 1 with Pertinent positive and negatives – REFERENCED – Where did you get this information from? Scholarly only.

Pertinent Positive with reference (LIST)

Pertinent Negative with reference (LIST)

 

1. REQUIRED – Differential Diagnosis 2 with Pertinent positive and negatives – REFERENCED – Where did you get this information from? Scholarly only.

Pertinent Positive with reference (LIST)

Pertinent Negative with reference (LIST)

PLAN

1. New tests or orders? Reference required.
2. Do you need referral to a specialist? If yes, what type and reason for referral.
3. What discharge instructions/Education will you give the patient? – Reference required.
4. How soon should the patient come back for follow-up? No reference required.
5. Medications? Basic level. Reference required.
6. Other recommendations including non-medicinal efforts? Reference required.

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