Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission

of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough

documentation in this section is essential for patient care, coding, and billing analysis. Paint a

picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender

(i.e., 34-year-old AA male). You must include the seven attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with

dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and

risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods

of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADLs and

IADLs if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems.

Review of Systems: From head to toe, include each system that covers the Chief Complaint, History

of Present Illness, and History (this includes the systems that address any previous diagnoses).

Remember that the information you include in this section is based on what the patient tells you.

You do not need to do them all unless you are doing a total H&P. To ensure that you include all

essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI

data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical

exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless

you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:
Vital signs: Include vital signs, height, weight, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include

dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience,

and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three

differential diagnoses, each of which must be supported with evidence and guidelines. Include any

labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For

holistic care, you need to include previous diagnoses and indicate whether these are controlled or

not controlled. These should also be included in your treatment plan.

PLAN:

Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies,

alternative therapies, follow-up recommendations, referrals, consultations, and any additional

labs, x-rays, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health

promotion strategies for the patient/family. Support the health promotion recommendations and

strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention

recommendations and strategies, such as fasting lipid profile, mammography, colonoscopy,

immunizations, etc. Support the disease prevention recommendations and strategies with evidence and

guidelines.

REFLECTION: Reflect on your clinical experience and consider the following questions: What did you

learn from this experience? What would you do differently? Do you agree with your preceptor based

on the evidence?