CC (reason for encounter): brief subjective description. You will type this and the HPI in the EHR section of the case (NOT the problem statement).
HPI (History of present illness): It can only be graded from this place!  You will receive a zero for this section if not in the correct place.   
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This is for subjective findings. Use LOCATES or OLDCARTS Mnemonic to complete your HPI, but this is meant to help you develop the paragraph and should not be headings in a professional note. You need to start EVERY HPI with age, race, and gender (e.g., 14-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. Include any pertinent history information that might impact the differential diagnosis formulation. If the CC was “headache,” the LOCATES for the HPI would include the following information: 
Onset: 3 days ago 
Location: head 
Duration: Lasts for an hour or two
Character: pounding, pressure around the eyes and temples 
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia 
Relieving factors/Exacerbating factors: light bothers eyes, Aleve makes it tolerable but not completely better 
Timing: after being on the computer all day at work 
Severity: 7/10 pain scale 
Management Plan Template– must include these headings: This section is worth 70 points.
1. Problem Statement – 5 pts 
Problem statement should include:
a. CC
b. Key subjective findings (symptoms)
c. Key objective findings (PE)
2. Primary Diagnosis, Differentials