1. The chart notes for each visit should be comprehensive enough to give the pertinent info without always needing to refer to every past visit -- at least carry over from visit to visit the identifying data, current medications and supplements, complete problem/concerns list.
2. Begin every ROC chart note with a brief phrase of identifying data: for example, "F/u on sinus headache treatment," "F/u on irregular menses, acne, and food allergies." When presenting the case in preview or review this introduction should be a whole sentence such as, "This is a 40 year old woman who comes in for evaluation of abdominal pain of 3 days duration." "This is a 56 year old man being treated here for hypertension and stress management, here today for a 3 month follow up."
3. Physical Exam normal findings. These suggestions cover only the basics. Choose only what is appropriate/useful, and remember that we need to be more specific with pertinent negative findings when we are ruling something out.
General appearance: Well nourished, well developed, (for given age range), male or female, in no acute/mild/moderate/acute distress ("distress" could refer to pain, respiratory distress, mental agitation, etc.). Even when you don't do a PE, please note something about the general appearance.
Skin: warm and dry
Head: Normocephalic, atraumatic
Eyes: PERRLA (pupils equally round and reactive to light and accommodation), EOMI (extra-ocular movements intact) (or you could say EOM's full), nonicteric, fundi benign (or: discs flat, no hemorrhages or exudates).
Ears: TM's clear bilaterally
Oropharynx: mucous membranes pink and moist
Neck: supple, non-tender, no nodes, no thyromegaly, trachea midline
Lungs: lung fields clear to percussion and auscultation
Heart: S1, S2 regular, no murmurs, gallops or rubs
Abdomen: flat (or concave or obese, etc), non-tender, active bowel sounds, no lesions, masses or organomegaly (if you have measured the liver span, note that)
Neurologic: Cranial Nerves II-XII intact. Gait, speech normal. (please specifically describe any strength, sensation and cerebellar function testing you do) DTR's intact. (Do enumerate specific findings as appropriate)
Extremities: no cyanosis, clubbing or edema, peripheral pulses intact gynecological:vulva: skin pink, no lesions, inguinal nodes non palpable(NP), female hair pattern, no nits
(eggs from lice)or insects observed