1. Legibility & Organization
   1. Write EVERYTHING down
      1. if you didn't chart it, you didn't do it
2. Name, DOB, Age, Gender, Date, Page #, & CC
   1. ON EVERY PAGE!!!
3. Subjective
   1. How pt is doing
      1. in their own words
         1. what is going on w pt?
   2. HPI
      1. History of presenting illness
         1. PQRST
            1. LMNO
   3. FH/SH
      1. Family and social history
   4. Diet/OH/drugs/nicotine/caffeine/water
   5. ROS
      1. Review of Systems
4. Objective
   1. What doctor observes about pt
   2. Vitals
      1. BP, RAS/LAS, pulse, bpm, rrr, temp, resp rpm
   3. PE
      1. Physical Exam
   4. M/E
      1. mental/emotional
   5. Lab results
5. Assessment
   1. Dx
      1. ICD-9 code
      2. What you assess about the pt's condition and response to trt
      3. most likely cause of condition
      4. if labs are ready, chart how the results lead you to your dx
      5. S + O = A
6. Plan
   1. Trt protocol
      1. everything you did today
         1. massage
   2. prescriptions
      1. Rx, supplements, herbs, homeop
   3. recommendations
      1. diet, hydro, exercise, mental health
   4. Labs ordered/done
   5. What to do next visit
   6. return to clinic as needed (RTC PRN)
   7. PARQ conference completed
      1. Plan Alternative Risk Questions