Place appropriate title here

DATE and TIME

USE CALIBRI FONT, SIZE 11 AND MARGINS SHOULD NOT BE CHANGED
S:

What is the patient telling you?

O:

Relevant vital signs

Relevant lab values
Relevant diagnostic tests

A:

SEPARATE ASSESSMENT AND PLAN FOR EACH DISEASE STATE

Separate by disease state and evaluate
Relevant disease #1 status/progression/goals (applicable information)/efficacy of
current treatment
Relevant disease #2 status/progression/goals (applicable information)/efficacy of
current treatment
ETC
All information should not be new information

P:

Separate by disease state

Relevant disease #1 (should be same order as above) complete recommendation
including drug therapy, TLC, patient counseling, follow up
Relevant disease #2 - complete recommendation including drug therapy, TLC, patient
counseling, follow up
Relevant disease #3 - complete recommendation including drug therapy, TLC, patient
counseling, follow up

Your Name,