What the patient tells you
CC and HPI, pertinent ROS to CC and HPI, Pertinent parts of the rest of history, Meds and allergy
Height, Weight, BMI, BP, T, P, R, Pain, General (well-developed, well-norished...), physical exam pertinent to the CC, lab/studies (that you have results for)
Numbered list of diagnosis, each diagnosis has a status (acute, improving, deteriorating, chronic), working diagnosis (most probable cause of the symptoms), DDX (differential diagnosis) = 3 possible causes, other Co morbid/chronic problems
what the pt tells you in their own words the reason fr their visit. may use quotes.
what do you write for subjective
This 43 yo Caucasian female with an unremarkable PMH presents for a follow up for cough X 14 days