Headings
Chief complaint · History of present illness · Review of systems · Examination · Assessment · Plan
When to use it
Use this for a same-day visit about one new problem, such as a sore throat, rash, sprain or urinary symptoms. It keeps the note tight around the chief complaint, a focused review of systems and exam, and a clear assessment and plan. It is shorter than a full history and physical, and it does not track chronic conditions over time.
Example
Fictional example
Chief complaint
Sore throat and fever for 2 days.
History of present illness
J.T., 28. Painful swallowing since Monday. Fever to 101.8 F at home. No cough. Partner had similar symptoms last week.
Review of systems
Positive for headache and fatigue. Negative for rash, ear pain, shortness of breath.
Examination
Temp 101.2 F. Tonsils enlarged with white exudate. Tender anterior cervical nodes. Lungs clear.
Assessment
Streptococcal pharyngitis. Centor score 4. Rapid strep test positive.
Plan
Amoxicillin 500 mg twice daily for 10 days. Ibuprofen 400 mg every 6 hours as needed. Off work 24 hours after first dose. Return if unable to swallow fluids or symptoms last beyond 3 days on treatment.