General Rule:

 ONLY DOCUMENT WHAT YOU HEARD.

 IT IS NOT IMPERATIVE TO FILL OUT ALL THE PARTS OF THE PROGRESS NOTES.
WRITE DETAILS BASED ON WHAT YOU HEARD
 USE THE TEMPLATE GUIDE AS guide.

Patient Chart

Patient ID: VT DAY 4 - 1

Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

Sore throat.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

Intro: This female patient came into the clinic/hospital with a chief complaint of sore
throat.

____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.

The patient reported her sore throat started 5 days ago.

____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.

The patient reports a sore throat localized to the anterior neck region.
____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

___________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.

________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.
____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.

The patient states she has been taking Amoxicillin for her sore throat for the past few
days; however, she reports no improvement in her symptoms.

____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.
___________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.
____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

The patient reports experiencing fever, the presence of skin rashes, and localized
abdominal pain on the left side.
____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.

The patient denies chest pain, shortness of breath, cough, nausea, vomiting, changes
in bowel habits, urinary urgency or frequency. She also denies any pain and swelling.

____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.

Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details

The patient denies any history of past illnesses.

Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past

The patient denies any history of previous abdominal surgery.

Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work

The patient reports attending a birthday party a few days ago, during which she
shared a drink with friends who were also sick.

Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency

Amoxicillin

Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.

Constitutional:
(+) fever
(-)

Head: (Nope! Headache is not for here.)

(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+) Anterior and submandibular lymphadenopathy
(-)

Eyes:
(+)
(-)

Ears:
(+)
(-)
Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+) Dry mucous membranes, Pharyngeal erythema (bilateral), Exudates, Dystonia
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+) Hypertrophic tonsils, Anterior and submandibular lymphadenopathy
(-)

Cardiovascular:
(+)
(-) shortness of breath

Respiratory:
(+) Anterior and submandibular lymphadenopathy.
(-) Cough, Shortness of breath

Gastrointestinal:
(+)
(-) Bowel changes

Genitourinary:
(+)
(-) Urine test

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+) Abdominal rashes
(-)
 Neurological:
(+)
(-)

Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
(-)

Allergic/Immunologic:
(+)
(-)

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.
Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment) IPP

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!) A

Chest/Breast:

Heart: (heart sound, rate, and rhythm) Gallop

Tachycardia S4 Gallop, 1/6

Gastrointestinal/ABDOMEN:
Very fine macular rash across abdomen and chest, A little bit sore

Genitourinary:

Lymphatic:

Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
 Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:
Abdominal rashes

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves – Intact/unremarkable
 Sensory and Motor Exams - Intact
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

 ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes
Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies

 To prescribe IV fluids
 To perform/order the following tests:
CBC
Metabolic panel
Mono Spot Test
Strep Test
Abdominal Ultrasound
Urinalysis

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
**Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
 **Erase starters when not in use.

 The patient was prescribed IV fluids to help with hydration.

 The patient was informed that she will undergo several tests, including a Mono
Spot Test, due to the presence of rashes.
 The patient was advised that no medications were prescribed for pain or
nausea at this time.

Patient Chart

Patient ID: VT DAY 4 - 1

Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.
____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.

____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

____________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.

____________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.

____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.
____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.

____________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.

____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.
____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.

Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details

Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past
Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work

Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency

Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.

Constitutional:
(+)
(-)

Head: (Nope! Headache is not for here.)

(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+)
(-)
Eyes:
(+)
(-)

Ears:
(+)
(-)

Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+)
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+)
(-)

Cardiovascular:
(+)
(-)

Respiratory:
(+)
(-)

Gastrointestinal:
(+)
(-)

Genitourinary:
 (+)
(-)

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+)
(-)

Neurological:
(+)
(-)

Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
(-)

Allergic/Immunologic:
(+)
(-)

Objective:

Vital Signs:
 Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.

Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment)

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!)

Chest/Breast:

Heart: (heart sound, rate, and rhythm)

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
 Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:

EXTREMITIES:
 Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

 description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies

 To

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
 **Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
**Erase starters when not in use.

 Informed the patient…

 Explained to the patient…
 Encouraged the patient…
 Discouraged the patient…
 Illustrated/Demonstrated the patient…
 Warned the patient..
 RTC/FFUP on….

Patient Chart

Patient ID: VT DAY 4 - 3

Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

Intro: This male patient came into the clinic/hospital with a chief complaint of bowel
problems.
____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.

____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.

____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

____________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.

____________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.
____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.

____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.

____________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.

____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.

____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.

Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details
Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past

Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work

Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency

Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.

Constitutional:
(+)
(-)
Head: (Nope! Headache is not for here.)
(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+)
(-)

Eyes:
(+)
(-)

Ears:
(+)
(-)

Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+)
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+)
(-)

Cardiovascular:
(+)
(-)

Respiratory:
(+)
(-)
Gastrointestinal:
(+)
(-)

Genitourinary:
(+)
(-)

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+)
(-)

Neurological:
(+)
(-)

Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
(-)

Allergic/Immunologic:
 (+)
(-)

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.

Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment)

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!)

Chest/Breast:

Heart: (heart sound, rate, and rhythm)

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
  Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:
ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies
  To

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
**Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
**Erase starters when not in use.

 Informed the patient…

 Explained to the patient…
 Encouraged the patient…
 Discouraged the patient…
 Illustrated/Demonstrated the patient…
 Warned the patient..
 RTC/FFUP on….

Patient Chart

Patient ID: VT DAY 3 - 4

Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

Intro: This female patient came into the clinic/hospital with a chief complaint of

____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.

____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.

____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

____________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.
____________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.

____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.

____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.

____________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.
____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.

____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.

Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details

Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past

Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work
Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency

Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.
Constitutional:
(+)
(-)

Head: (Nope! Headache is not for here.)

(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+)
(-)

Eyes:
(+)
(-) light sensitivity

Ears:
(+)
(-)

Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+)
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+)
(-)

Cardiovascular:
(+)
(-)
Respiratory:
(+)
(-)

Gastrointestinal:
(+)
(-)

Genitourinary:
(+)
(-)

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+)
(-)

Neurological:
(+)
(-)

Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
 (-)

Allergic/Immunologic:
(+) Sofa
(-)

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.

Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment)

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!)

Chest/Breast:

Heart: (heart sound, rate, and rhythm)

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:
Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
 Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:
Assessment & Plan:
Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:
 Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
**Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
**Erase starters when not in use.




Patient Chart

Patient ID:

Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

Intro: This male/female patient came into the clinic/hospital with a chief complaint of
_______.

____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.

____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.

____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

____________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.
____________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.

____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.

____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.

____________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.
____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.

____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.
Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details

Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past

Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work

Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency
Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.

Constitutional:
(+)
(-)

Head: (Nope! Headache is not for here.)

(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+)
(-)

Eyes:
(+)
(-)

Ears:
(+)
(-)

Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+)
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+)
(-)

Cardiovascular:
(+)
(-)

Respiratory:
(+)
(-)

Gastrointestinal:
(+)
(-)

Genitourinary:
(+)
(-)

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+)
(-)

Neurological:
(+)
(-)
 Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
(-)

Allergic/Immunologic:
(+)
(-)

Objective:

Vital Signs:

Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.

Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment)

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!)

Chest/Breast:

Heart: (heart sound, rate, and rhythm)

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
 Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:

EXTREMITIES:

Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
 Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:
 E/M Code Builder Superbill
CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies

 To

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
**Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
**Erase starters when not in use.

 Informed the patient…

 Explained to the patient…
 Encouraged the patient…
 Discouraged the patient…
 Illustrated/Demonstrated the patient…
 Warned the patient..
 RTC/FFUP on….

Patient Chart

Patient ID:
 Progress Notes
Subjective:

Chief Complaint:

Read me first!
Write the main concern/concerns of the patient.

History of Present Illness:

Read me first!
**HPI story starts from the onset of the chief complaint up to the time the patient is
talking with the doctor in the clinic.
**Make sure to state your details in full and complete sentences. A sentence begins
with a capital letter, ends with a period, and has a subject, a verb, and an object.
**Make sure to only put details that answer the questions asked.
**A detail should not be stated more than once.

Intro: This male/female patient came into the clinic/hospital with a chief complaint of
_______.

____________________________________________________________________
O – When/Where/How the chief complaint started? **Only write details that answer
these questions.

____________________________________________________________________
L – Where is the location of the chief complaint? **Only write details that answer
this question.
____________________________________________________________________
D – How long has the chief complaint been going on?/ How long does it last? What is
the length of time the chief complaint happened? **Only write details that answer
these questions.

____________________________________________________________________
C – What kind of chief complaint is it? **Only write details that answer this
question.

____________________________________________________________________
A – What situations/events/activities worsen the chief complaint? **Only write details
that answer these questions.

____________________________________________________________________
R – What situations/events/activities/medications make the chief complaint better?
**Only write details that answer these questions.
____________________________________________________________________
T – Does the chief complaint happen regularly like every day or twice a week, etc.?/
Does the chief complaint happen repeatedly? / Is the chief complaint getting worse,
getting better, or just the same ever since? **Only write details that answer these
questions.

____________________________________________________________________
S – What is the pain scale? ( only for pain chief complaint) / What are situations
interfered by the chief complaint? (situations that the patient could normally do before
but cannot do now because of the chief complaint.) **Only write details that answer
these questions.

____________________________________________________________________
(+) What are symptoms claimed by the patient other than the chief complaint? **Only
write details that answer these questions.

____________________________________________________________________
(-) What are symptoms denied by the patient other than the chief complaint? **Only
write details that answer this question.
____________________________________________________________________
Perception: What does the patient think what is going on with him/her? **Only write
details that answer this question.

Past History:

Read me first!
**It is NOT necessary to write details here in full sentences.
**Past History are details that happened BEFORE the onset of the Chief Complaint.
**Make sure to fully spell every abbreviations and acronyms all throughout the
Progress Notes.

Medical History:

Read me first!
**Diseases the patient is diagnosed with in the past
**Prior hospitalization
**Pregnancy
**Immunization
**Last Menstrual Period
**Other OB related details

Surgical History:

Read me first!
**Injuries in the past
**Surgical procedures in the past
Family History:

Read me first!
**Illnesses that run in the family
**Family members who are affected by familial diseases
**Year/age family member(s) died

Social History:

Read me first!
**marital status
**lifestyle
**Activities of daily living
**Exercise/physical activities
**Use of prohibited drugs/alcohol
**Sexual activities/orientation/partners
**dietary habits
**Travel history
**Work

Smoking History:

Read me first!
**How many stick/packs
**Onset of smoking
**Smoking cessation

Allergies:

Read me first!
**Allergens
**Reaction
**Severe reaction
**No Known (Drug/Food) Allergy

Current Medications:

Read me first!
**Relieving factor medication
**Maintenance medication
**Dosage/Frequency

Review of Systems:

Read me first!
**Copy-paste your CC and associated symptoms in HPI and distribute the symptoms
to the system where they belong to here in ROS.
**Just distribute the symptoms ONLY, not the entire sentence.
**Use the Template Guide file to guide you where to put the details accurately. If a
symptom is not in the Guide, Google.

Constitutional:
(+)
(-)

Head: (Nope! Headache is not for here.)

(+)
(-)

Neck: (Nope! Neck pain is not for here.)

(+)
(-)
Eyes:
(+)
(-)

Ears:
(+)
(-)

Nose:
(+)
(-)

Mouth: (Nope! Bad breath is not for here.)

(+)
(-)

Throat: (Nope! Difficulty swallowing is not for here.)

(+)
(-)

Cardiovascular:
(+)
(-)

Respiratory:
(+)
(-)

Gastrointestinal:
(+)
(-)

Genitourinary:
 (+)
(-)

Musculoskeletal: (Nope! Muscle weakness/numbness/tingling is not for here.)

(+)
(-)

Integumentary (skin and/or breast):

(+)
(-)

Neurological:
(+)
(-)

Psychiatric:
(+)
(-)

Endocrine: (Excessive hunger, thirst, and urination, here! Here! Here!)

(+)
(-)

Hematologic/Lymphatic:
(+)
(-)

Allergic/Immunologic:
(+)
(-)

Objective:

Vital Signs:
 Height: Weight: BMI Interp: Systolic: Diastolic:

Pulse (beats/min):

Physical Examination:

Read me first!
**You know when it is PE time once you notice the doctor starts touching the patient.
**IPPA! Except for GI – IAPP
**Use the Template Guide file to guide you where to put details accurately.
**If a system is not examined, then leave it blank.
**If a system is examined but the doctor did not say what the finding is, write unremarkable.

Constitutional:

EENT:

NECK: ( Nope nope nope! JVD – jugular vein distention and carotid bruit are not for here)

Respiratory: ( thoracic/upper back assessment)

CARDIO: (blood/blood vessel/circulatory-related)

Lungs: (lung sounds!)

Chest/Breast:

Heart: (heart sound, rate, and rhythm)

Gastrointestinal/ABDOMEN:

Genitourinary:

Lymphatic:

Musculoskeletal Weakness, strength, and reflex findings are not for here! They are neuro. Musculo is purely for IPP

 Knee exam- IPP ONLY

 Shoulder exam IPP ONLY
 Hand exam IPP ONLY
 Elbow exam: IPP ONLY
 Hip exam IPP ONLY
 Lower back exam - IPP ONLY

SKIN:

EXTREMITIES:
 Neurologic/Psychiatric:
 Cranial Nerves
 Sensory and Motor Exams
 Reflex testing-
 Coordination
 Gait testing

Test Result Exams:

ECG:

EKG reading:
Rate:
Rhythm:
Axis:
Ectopy:
Conduction:
P wave:
Q wave:
ST-T wave changes:
Comparison:
Impression:
Image:

Labs:

Assessment & Plan:

Diagnosis Codes:

ICD Type:

ICD 10

ICD 10 Codes

Select Codes:

A (1 Start typing code or G(7) Start typing code or

 description description

Assessment Notes Assessment

Notes

B (2) Start typing code or H (8) Start typing code or

description description

Assessment Notes Assessment

Notes

C (3) Start typing code or I (9) Start typing code or

description description

Assessment Notes Assessment

Notes

Reviewed:

Procedures:

E/M Code Builder Superbill

CPT Description POS Modifier ICD-10 Line Days NDC
Pointer Charges or
Units

A B C D

Plan Notes:

Read me first!
**Things the medical team will do to and for the patient
**Begin with ‘To…’ No period!
**Labs, meds, diagnostics, referral to other medical allies

 To

Patient Instructions/Follow Up:

Read me first!
**Details the patient needs to know
**What is the diagnosis?
**Detailed explanation of health teaching. Yes, detailed.
**Explanation/Reason for doing labs and diagnostics
**Specific lifestyle changes
**Health teaching
**Statements are stated in full sentences here again.
**When to return to clinic
**Erase starters when not in use.

 Informed the patient…

 Explained to the patient…
 Encouraged the patient…
 Discouraged the patient…
 Illustrated/Demonstrated the patient…
 Warned the patient..
 RTC/FFUP on….