1. Biographical Data, Source and Reliability of Information, Reason for Seeking Care are complete.
2. History of Present Illness is written in paragraph form.
3. Review of Systems (Subjective data)– discuss history of each system and use abbreviated format, not complete sentences: general, psychiatric, skin, hair, nails, lymph nodes, HEENT (head, eyes, ears, nose, mouth, throat), neck, blood, breasts, cardiovascular, respiratory, GI, GU, musculoskeletal, neurologic, endocrine