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Examples of general education comment to assist in compliant chart notes on patients

These are general education comment to assist physicians in recording compliant chart notes on patients. The  Chief Complaint:  This should be a concise statement from the patient that describes the reason for today's encounter. The History of Present Illness  (HPI) :    This consists of a description of the patient's present complaint(s)……..try to include location….quality…..severity…..duration…….timing……context…..modifying factors………..associated signs and symptoms. The Review of Systems (ROS):   This is an inventory of (any/all) body systems,  it is obtained by asking the patient a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The Past/Family/ and/or Social History (PFSH):   Past = illnesses, surgeries, injuries and treatments   Family = a review of medical events, diseases and hereditary conditions that may place the patient at risk   AND   Soc...