You should also include what impact the patient's illness has had on their psychosocial situation. These are best listed with a new line for each entry to aid the reader in reviewing this information. If the disease process was mentioned in the HPI, don't repeat it again here. Family History should include all blood relatives, illnesses, ages, if deceased and cause of death if known. They can be listed by person or in a genetic tree format.
First line describes the patient's appearance.
Vital signs including weight. Sometimes people find it easier to first list all the problems before moving on to the Assessment and Plan. In this section, you write about what you think is going on and why. You formulate a differential diagnosis and substantiate it with information from the history and physical and support it with facts and clinical reasoning. You need not formulate an exhaustive differential diagnosis but rather address all reasonable possibilities.