Demographic Data
* Age, and gender (must be HIPAA compliant) Subjective
* Chief Complaint (CC) unless an Annual Physical Exam (APE)
* History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
* Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies,