See example template below for required format.  
Demographic Data

Age, and gender (must be HIPAA compliant) 
Subjective 
Chief Complaint (CC) unless an Annual Physical Exam (APE) 

History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment) 

Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable 
Family Hx: As applicable 

Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. 
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) 
Objective 

Vital signs 

Physical findings listed by body systems, not paragraph form 
Assessment (Diagnosis/ICD10 Code) 
Include all diagnoses that apply for this visit 

Plan 
Dx Plan (lab, x-ray) 

Tx Plan: (meds) 

Pt. Education, including specific medication teaching points            

Referral/Follow-up 

Health maintenance (including when screenings, immunizations, etc., are next due): 
SCENARIO AND TEMPLATE WILL BE PROVIDED