1) Identifying Data ( 5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2) Subjective Data ( 3Opts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manitestations.(10pts). b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx, social hx, allergies, medications related to the complainVproblem (10pts). If more than one chief complaint, each should be written u in this manner.
3) Objective Data(25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.
Sample Solution
