Patient Scenario
A 40-year-old female comes in for her annual well exam. She denies any concerns.
Make sure to include all aspects of the subjective components:
1. Past medical history
2. Surgical history
3. Family history
4. Social history
5. Medication list
6. Required immunizations
7. Medication, food, environmental, or other allergies
8. Complete review of systems (ROS).
Make sure to include all aspects of the objective components:
1. Complete physical exam
2. Diagnosis/assessment (including ICD-10-CM and CPT codes for an established patient.
3. Treatment plan. Explicitly provide health promotion and disease prevention interventions in anticipatory guidance.
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