Patient Scenario
A 50-year-old male presents to the clinic for his annual physical exam. He 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. Medication, food, environmental, or other allergies
7. Required or recommended immunizations
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 codes 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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