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The History and Physical (H&P) form is a crucial document in the healthcare process, serving as a comprehensive summary of a patient's medical background and current health status. It begins with essential patient information, including name, age, and the reason for the visit, which sets the stage for a thorough examination. The form collects details about the patient's chief complaint and allergies, as well as a history of present illness that outlines the symptoms and concerns prompting the consultation. Medications and dosages are documented to ensure accurate treatment, while past medical and surgical history provides context for the patient's overall health. Social and family histories contribute additional insights that may affect diagnosis and care. The H&P includes a comprehensive review of systems, covering various body systems such as cardiovascular, respiratory, gastrointestinal, and neurological, allowing healthcare providers to identify any underlying issues. Finally, the physical examination section captures vital signs and findings from the examination, leading to an assessment and plan that guides further medical decisions. This structured approach ensures that all relevant information is gathered efficiently, facilitating effective patient care.

Sample - History And Physical Form

Inpatient History & Physical Form

Patient Stamp

 

Internal Medicine

 

 

Greenville Hospital System

 

 

( ) Initial Visit

( ) Consult requested by:

 

 

Date:

Service:

NAME:

AGE:

1º MD:

Attending:

MRN:

ROOM#:

 

 

Chief Complaint/Reason for Consult:

Allergies:

History of Present Illness:

Medications and Dosages:

Past Medical/Surgical History:

Social History:

Family History:

Page 1 of 4

Comprehensive Review of Systems

ROS NOT OBTAINABLE BECAUSE

Patient Stamp

Constitutional:

 

Genitourinary:

 

YES NO

DESCRIBE

YES NO

DESCRIBE

Fever, sweats or chills

 

Dysuria, frequency or urgency

 

Menstrual irregularities

 

Fatigue, anorexia, weight loss or gain

 

LMP ___________________

Weakness

 

 

Frequent UTI’s

 

 

 

 

 

 

Pain/Hematuria

 

Skin:

 

Musculoskelatal:

Rashes, no skin breakdown

 

Muscle aches, arthralgias or arthritis

 

 

 

 

 

Neurologic:

 

 

Mental status changes

Head:

 

 

Headaches

Headache

 

 

Dizziness

Visual changes

 

 

Weakness or numbness

Earache, sinus problems, sore throat

 

 

Seizures

Cough, snoring or mouth ulcers

 

 

Ataxia

 

 

 

 

Hematopoietic:

 

 

Lymphadenopathy

 

 

Bleeding tendencies

 

 

 

Cardiovascular:

 

Psychiatric:

Chest pain or palpitations

 

History of anxiety or depression

Syncope

 

Hallucinations/Delusions

Edema

 

 

 

 

 

 

 

Endocrine:

 

 

History of diabetes

 

 

History of thyroid problems

 

 

 

 

 

Other Symptoms:

Respiratory:

 

 

Shortness of breath

 

 

Cough or sputum production

 

 

Dyspnea on exertion orthopnea

 

 

Pleuritic chest pain

 

 

 

 

 

Gastrointestinal:

 

 

Heartburn, dysphagia

 

 

Nausea or vomiting

 

 

Diarrhea or constipation

 

 

Melena or BRBPR

 

 

Hematemesis

 

 

Abdominal pain

 

 

Page 2 of 4

Patient Stamp

Physical Exam

 

 

Labs and Studies

Vitals:

 

 

 

CBC:

 

Wt:

Temp:

BP:

P:

 

 

HT:

Resp:

Sat:

 

 

 

Constitutional:

nl general appearance

 

 

 

 

 

 

 

 

 

Head:

 

Normo-cephalic/atraumatic

 

BMP:

 

 

 

PERRLA

 

 

 

 

 

EOMI

 

 

 

 

 

nl sclera

 

 

 

 

 

Vision

 

 

 

Ears, Nose, Mouth & Throat:

 

CXR:

 

 

 

nl inspection of nasal

 

 

 

 

 

mucosa, septum, turbinates,

 

 

 

 

teeth, gums & oropharynx

 

 

 

 

nl ear canal and T

 

 

 

 

 

 

 

 

 

Neck:

 

nl neck appearance &

 

EKG:

 

 

 

jugular veins

 

 

 

 

 

Thyroid not palpable, non-tender

 

 

 

 

 

 

 

 

Lymph Nodes

 

nl neck, supraclavicular

 

 

 

 

 

or axillary adenopathy

 

 

 

 

 

 

 

 

Skin/Extremities:

Rashes, lesions or ulcers

 

 

 

 

 

Digits & nails

 

 

 

 

 

Edema

 

 

 

Breast Evaluation:

No skin changes

 

 

 

 

 

No nipple discharge

 

 

 

 

 

No lumps/masses

 

 

 

 

 

Fibrocystic changes

 

 

 

Respiratory:

 

Chest symmetric, nl chest

 

 

 

 

Expansion & respiratory effort

 

 

 

 

nl auscultation

 

 

 

 

 

nl chest percussion &

 

 

 

 

 

palpation

 

 

 

Cardiovascular:

Reg rhythm

 

 

 

 

 

No murmur, gallop or rub

 

 

 

 

Periph vasc no by ovserv &

 

 

 

 

palpation

 

 

 

Gastrointestinal:

No tenderness or masses

 

 

 

 

 

Liver & spleen not felt

 

 

 

 

 

nl bowel sounds

 

 

 

 

 

Heme negative stool

 

 

 

Musculoskeletal:

nl muscle strength, movement &

Neurologic:

Alert and oriented

 

 

tone, no focal atrophy

 

 

nl reflexes upper and lower

 

 

nl gait & station

 

 

extremities

 

 

 

 

 

Cranial nerves intact

Genito-urinary:

no pelvic exam

 

Psychiatric:

 

 

 

nl testes

 

 

nl mood/affect

Page 3of 4

Patient Stamp

Assessment:

Plan:

Attending HPI:

Attending PE:

Attending Assessment and Plan:

Resident signature:

MD

PGY1, PGY2, PGY3 Date:

Pager:

/1439

Resident name printed:

Dictated by:

Intern Pager:

/1872

Attending signature:

 

Date:

 

.

 

Attending: Ansari Atkisson Bowers Bruch Call Chang Cochrane Curran Ferraro Fuller Gilroy Hayes Kelly Knight Latham McCraw McFarland Meyer North-Coombes Schrank Sinopoli Smith Surka Von Hofe Wagstaff Watson Weber Weems White

Page 4 of 4

↓ History And Physical PDF

File Specs

Fact Name Description Governing Law(s)
Purpose The History and Physical form is used to document a patient's medical history and physical examination findings. It serves as a critical tool for healthcare providers to assess a patient's health status. State Medical Practice Acts
Content Requirements The form typically includes sections for patient demographics, chief complaint, history of present illness, medications, past medical history, and a comprehensive review of systems. HIPAA Privacy Rule
Legal Significance Accurate completion of the History and Physical form is essential for legal documentation and may be used in malpractice cases to demonstrate the standard of care provided. State Tort Law
Patient Consent Patients must provide consent for their medical information to be documented and shared. This is crucial for compliance with privacy regulations. HIPAA Privacy Rule
State Variations Some states may have specific requirements for the History and Physical form, including additional documentation or specific formats mandated by state law. State Medical Board Regulations

History And Physical - Usage Guidelines

Completing the History and Physical form is an important step in ensuring that all relevant patient information is accurately recorded. This process will help healthcare providers make informed decisions about the patient's care. Follow these steps carefully to fill out the form correctly.

  1. Begin by filling in the patient stamp section at the top of the form, including the patient's name, age, medical record number (MRN), and room number.
  2. Indicate whether this is an initial visit or a consult by checking the appropriate box.
  3. Enter the date of the visit and the service being provided.
  4. Document the chief complaint or reason for the consult in the designated area.
  5. List any known allergies in the allergies section.
  6. Provide a detailed history of the present illness, including symptoms and duration.
  7. Record all medications the patient is currently taking, along with their dosages.
  8. Summarize the past medical and surgical history of the patient.
  9. Include social history, such as lifestyle factors and habits that may affect health.
  10. Document any relevant family history that may impact the patient's health.
  11. Complete the comprehensive review of systems, indicating "yes" or "no" and providing descriptions where applicable.
  12. Fill out the physical exam section, including vital signs and findings from the examination.
  13. Record any labs and studies that have been conducted, including CBC, BMP, CXR, and EKG results.
  14. Provide an assessment and plan based on the findings from the history and physical examination.
  15. Sign the form as the attending physician and include the date.
  16. Ensure the resident's name and pager number are included if applicable, and have the intern sign as well.

Your Questions, Answered

What is the purpose of the History and Physical form?

The History and Physical (H&P) form is used to collect comprehensive information about a patient's medical history and current health status. It serves as a foundational document for healthcare providers to assess a patient's condition, plan treatment, and ensure continuity of care. The form includes sections for personal information, medical history, and a physical examination, which together help in making informed clinical decisions.

What information is typically included in the History and Physical form?

The H&P form generally includes sections for the patient's demographic details, chief complaint, allergies, medications, past medical and surgical history, social history, and family history. Additionally, it contains a comprehensive review of systems (ROS) to evaluate various body systems and a physical examination section to document findings from the clinical assessment.

How is the History and Physical form used in inpatient settings?

In inpatient settings, the H&P form is crucial for documenting a patient's health status upon admission. It allows the healthcare team to understand the patient's medical background, current issues, and any treatments that may be necessary. This information is vital for developing a personalized care plan and for ongoing evaluations during the hospital stay.

Who is responsible for completing the History and Physical form?

What is the significance of the Review of Systems (ROS) section?

The Review of Systems (ROS) section is significant because it provides a systematic approach to identifying any symptoms that may not have been disclosed during the patient interview. This part of the form helps ensure that all potential health issues are considered, facilitating a thorough evaluation and comprehensive care plan.

How does the physical examination section contribute to patient care?

The physical examination section allows healthcare providers to document their findings based on a hands-on assessment of the patient. This information is essential for identifying any abnormalities or concerns that may require further investigation or intervention. It also helps establish a baseline for monitoring the patient’s progress during treatment.

What role does the assessment and plan section play in the H&P form?

The assessment and plan section is critical as it summarizes the healthcare provider's clinical impressions based on the history and physical examination. It outlines the proposed treatment plan, including any necessary tests, medications, or referrals. This section guides the ongoing management of the patient's care and ensures that all team members are aligned on the treatment strategy.

How often should the History and Physical form be updated?

The H&P form should be updated whenever there is a significant change in the patient's condition, upon transfer to a different level of care, or at regular intervals during a hospital stay. Regular updates ensure that all healthcare providers have the most current information for making clinical decisions.

What happens to the History and Physical form after it is completed?

Once completed, the H&P form becomes part of the patient's medical record. It is stored securely in accordance with healthcare regulations and is accessible to authorized healthcare providers involved in the patient's care. This ensures that all team members can review the information as needed for ongoing treatment and evaluation.

Is the History and Physical form required for all patients?

Yes, the History and Physical form is typically required for all patients admitted to a hospital or receiving certain types of outpatient care. It is a standard practice that helps ensure comprehensive care and thorough documentation, promoting patient safety and effective treatment outcomes.

Common mistakes

  1. Incomplete Patient Information: Failing to fill in all personal details, such as name, age, and medical record number (MRN), can lead to confusion and delays in care.

  2. Missing Chief Complaint: Not clearly stating the chief complaint or reason for the visit may result in misunderstandings about the patient's primary health concern.

  3. Ignoring Allergies: Omitting allergies can pose serious risks. It is crucial to list any known allergies to medications, foods, or other substances.

  4. Neglecting Medical History: Failing to provide a complete past medical and surgical history can prevent healthcare providers from making informed decisions about treatment.

  5. Inaccurate Medication List: Listing incorrect medications or dosages may lead to dangerous interactions. Always ensure that the medication list is up to date and accurate.

Documents used along the form

The History and Physical (H&P) form is a critical document used in healthcare settings to gather comprehensive information about a patient's medical history and current health status. Alongside the H&P, several other forms and documents are often utilized to ensure that patient care is thorough and well-coordinated. Below is a list of these essential documents, each serving a specific purpose in the healthcare process.

  • Admission Orders: This document outlines the initial treatment plan for a patient upon admission to the hospital. It includes medication prescriptions, tests to be conducted, and any special instructions for nursing staff.
  • Medication Administration Record (MAR): The MAR is a detailed log that tracks all medications administered to a patient during their hospital stay. It helps ensure that medications are given on time and at the correct dosages.
  • Progress Notes: Healthcare providers use progress notes to document a patient’s ongoing condition and response to treatment. These notes are updated regularly and provide a chronological account of the patient’s health status.
  • Discharge Summary: This document is prepared at the time of a patient’s discharge. It summarizes the hospital stay, including diagnoses, treatments received, and follow-up care instructions.
  • Consent Forms: Before certain procedures or treatments, patients must sign consent forms. These documents confirm that patients understand the risks and benefits of the proposed medical interventions.
  • Lab Results: Lab results provide critical information about a patient’s health, including blood tests, imaging studies, and other diagnostic tests. These results are essential for making informed treatment decisions.
  • Referral Forms: When a patient needs to see a specialist, referral forms are used to communicate necessary information about the patient’s condition and the reason for the referral. This ensures continuity of care across different providers.

Each of these documents plays a vital role in patient care, facilitating communication among healthcare professionals and ensuring that patients receive comprehensive and coordinated treatment. Understanding these forms can empower patients and their families to engage more effectively in their healthcare journey.

Similar forms

The Admission Note is a document that serves a similar purpose to the History and Physical form. It is typically created during a patient's initial visit to a healthcare facility. The Admission Note includes essential information such as the patient's chief complaint, medical history, and a summary of the physical examination. Like the History and Physical form, it provides a foundation for ongoing patient care and is crucial for healthcare providers to understand the patient's current health status.

The Progress Note is another document that bears similarities to the History and Physical form. This note is used to track a patient's condition and response to treatment over time. It often includes updates on the patient's symptoms, changes in medications, and results from any new tests or procedures. Both the Progress Note and the History and Physical form contribute to a comprehensive understanding of the patient's health journey, enabling healthcare providers to make informed decisions about ongoing care.

The Discharge Summary is also comparable to the History and Physical form. It is created when a patient is ready to leave the hospital or healthcare facility. This document summarizes the patient's hospital stay, including diagnoses, treatments received, and any follow-up care that may be necessary. Like the History and Physical form, the Discharge Summary serves as a critical communication tool among healthcare providers and helps ensure continuity of care after the patient leaves the facility.

Lastly, the Consultation Report shares similarities with the History and Physical form. This document is generated when a specialist evaluates a patient referred by another healthcare provider. The Consultation Report includes the specialist's findings, recommendations, and any relevant medical history. Both documents aim to provide a thorough understanding of the patient's health and facilitate collaboration among different members of the healthcare team.

Dos and Don'ts

When filling out the History and Physical form, it is crucial to ensure accuracy and completeness. Here are some important dos and don'ts to keep in mind:

  • Do provide clear and concise information about your chief complaint.
  • Do list all medications you are currently taking, including dosages.
  • Do mention any allergies you have, even if they seem minor.
  • Do include relevant past medical and surgical history.
  • Don't leave any sections blank; if something does not apply, indicate that clearly.
  • Don't exaggerate symptoms or downplay their severity; honesty is key.
  • Don't forget to update your social and family history, as it can be significant for your care.

Misconceptions

  • Misconception 1: The History and Physical (H&P) form is only for new patients.

    This is not true. The H&P form is essential for both new and returning patients. It helps healthcare providers understand a patient's current health status and any changes since their last visit.

  • Misconception 2: The H&P form is only about medical history.

    While medical history is a significant part, the H&P form also includes social and family history. This information is crucial for understanding potential health risks and tailoring treatment plans.

  • Misconception 3: Completing the H&P form is a quick process that doesn't require much detail.

    In reality, the H&P form requires thorough and accurate information. Detailed responses can lead to better diagnosis and treatment. Taking time to fill it out properly is important.

  • Misconception 4: The H&P form is not important for ongoing treatment.

    This is incorrect. The H&P form serves as a foundational document for ongoing care. It helps healthcare providers track changes in a patient’s condition and adjust treatment as necessary.

Key takeaways

Filling out and using the History and Physical (H&P) form is crucial for providing comprehensive patient care. Here are some key takeaways to consider:

  • Complete Information: Ensure all sections of the form are filled out accurately. This includes the patient's chief complaint, medical history, and current medications.
  • Review Systems Thoroughly: Conduct a comprehensive review of systems (ROS). This helps in identifying any underlying issues that may not be immediately apparent.
  • Physical Exam Details: Document findings from the physical exam meticulously. Highlight any abnormalities or concerns to guide further treatment.
  • Assessment and Plan: Clearly articulate the assessment of the patient’s condition and outline a plan for further management. This should be a collaborative effort between the attending physician and the resident.
  • Signature Requirements: Ensure that all necessary signatures are obtained. This includes the attending physician and any residents involved in the patient's care.
  • Confidentiality: Maintain patient confidentiality at all times. Securely handle the H&P forms to protect sensitive information.

By adhering to these guidelines, healthcare providers can enhance communication and ensure that all relevant patient information is effectively utilized in their care plans.