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Establish Care- Well Visit
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Establish Care- Sick Visit
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F/U Visit
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Following up on:
• • •
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Followup free text
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Improvement / No Improvement
• • •
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Lab Review
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Lab Review + Complaint / Sick Visit
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Medication Refill Only
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Medication Refill + Complaint / Sick Visit
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Diagnostics Review
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Diagnostics Review + Complaint / Problem
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Chief Complaint
• • •
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C/C in the patient's own words
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ONSET
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The onset of the problem began
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Hours/Days/Months/Years
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LOCATION
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Location
• • •
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Location Comments
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DURATION
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Duration
• • •
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Duration Comments
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CHARACTERISTICS
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Quality
• • •
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Quality Comments
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ASSOCIATED SYMPTOMS
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Pertinent Negatives
• • •
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Pertinent negative text
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AGGRAVATING FACTORS
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Context
• • •
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Context Comments
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RELIEVING FACTORS
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Modifying Factors
• • •
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Modifying Factors Comments
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TIMING
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Timing
• • •
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Timing Comments
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SEVERITY
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Severity
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Severity Comments
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Previous Treatment
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F/U Visit + NO Improvement
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