9.0 KiB
History and Physical Examination (H&P) Template
Patient Name: [Last, First]
Medical Record Number: [MRN]
Date of Birth: [MM/DD/YYYY]
Age: [years]
Sex: [M/F]
Date of Admission/Encounter: [MM/DD/YYYY]
Time: [HH:MM]
Location: [Hospital floor, Clinic, ED]
Admitting Service: [Medicine, Surgery, etc.]
Attending Physician: [Name]
Chief Complaint (CC)
"[Patient's stated reason for seeking care, in quotes]"
History of Present Illness (HPI)
[Patient Name] is a [age]-year-old [sex] with a history of [relevant PMHx] who presents with [chief complaint].
[Use OPQRST format for symptoms, provide chronological narrative]
Onset: [When did symptoms start? Sudden vs gradual onset?]
Location: [Where? Does it radiate?]
Duration: [How long?]
Character: [Quality - sharp, dull, pressure, etc.]
Aggravating factors: [What makes it worse?]
Relieving factors: [What makes it better?]
Timing: [Constant or intermittent? Pattern?]
Severity: [0-10 scale for pain, functional impact]
Associated symptoms: [Other symptoms?]
Prior evaluations and treatments:
Why presenting now:
Past Medical History (PMH)
- [Condition] - diagnosed [year], [current status]
- [Condition] - diagnosed [year], [treatment]
- [Additional conditions]
[ ] No known medical problems
Past Surgical History (PSH)
- [Procedure] ([year]) - [indication, complications if any]
- [Procedure] ([year])
[ ] No prior surgeries
Medications
| Medication | Dose | Route | Frequency | Indication |
|---|---|---|---|---|
| [Drug name] | [mg] | [PO/IV/etc] | [BID/etc] | [Why prescribed] |
[ ] No current medications
Allergies
| Allergen | Reaction |
|---|---|
| [Drug/Food/Environmental] | [Type of reaction] |
[ ] No known drug allergies (NKDA)
Family History (FH)
- Father: [Age/deceased at age X], [medical conditions]
- Mother: [Age/deceased at age X], [medical conditions]
- Siblings: [Number], [relevant conditions]
- Children: [Number], [relevant conditions]
[Note hereditary conditions relevant to patient's presentation]
[ ] Non-contributory
Social History (SH)
Tobacco: [Current/former/never], [pack-years if applicable]
Alcohol: [Frequency and amount, CAGE questions if indicated]
Illicit drugs: [Current/former/never, type, route]
Occupation: [Current or former occupation]
Living situation: [Lives alone/with family, housing type]
Marital status: [Single/married/divorced/widowed]
Sexual history: [If relevant]
Exercise: [Type and frequency]
Diet: [General diet description]
Functional status: [ADL independence, baseline activity level]
Review of Systems (ROS)
[Systematic review - check relevant systems]
Constitutional: [ ] Fever [ ] Chills [ ] Night sweats [ ] Weight loss [ ] Weight gain [ ] Fatigue
Eyes: [ ] Vision changes [ ] Eye pain [ ] Discharge
ENT: [ ] Hearing loss [ ] Tinnitus [ ] Sinus problems [ ] Sore throat
Cardiovascular: [ ] Chest pain [ ] Palpitations [ ] Edema [ ] Orthopnea [ ] PND [ ] Claudication
Respiratory: [ ] Dyspnea [ ] Cough [ ] Wheezing [ ] Hemoptysis
Gastrointestinal: [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ] Abdominal pain [ ] Melena [ ] Hematochezia
Genitourinary: [ ] Dysuria [ ] Frequency [ ] Urgency [ ] Hematuria [ ] Incontinence
Musculoskeletal: [ ] Joint pain [ ] Swelling [ ] Stiffness [ ] Back pain [ ] Weakness
Skin: [ ] Rash [ ] Lesions [ ] Itching [ ] Changes in moles
Neurological: [ ] Headache [ ] Dizziness [ ] Syncope [ ] Seizures [ ] Weakness [ ] Numbness [ ] Tingling
Psychiatric: [ ] Depression [ ] Anxiety [ ] Sleep disturbance
Endocrine: [ ] Heat/cold intolerance [ ] Polyuria [ ] Polydipsia [ ] Polyphagia
Hematologic/Lymphatic: [ ] Easy bruising [ ] Bleeding [ ] Lymph node swelling
Allergic/Immunologic: [ ] Seasonal allergies [ ] Frequent infections
All other systems reviewed and negative [ ]
Physical Examination
Vital Signs:
- Temperature: _____ °F (oral/axillary/tympanic)
- Blood Pressure: / mmHg ([right arm, sitting])
- Heart Rate: _____ bpm (regular/irregular)
- Respiratory Rate: _____ breaths/min
- Oxygen Saturation: _____% on [room air / O2 at ___ L/min]
- Height: _____ cm / inches
- Weight: _____ kg / lbs
- BMI: _____ kg/m²
- Pain Score: ___/10
General:
[Overall appearance, apparent vs stated age, nutritional status, distress level]
HEENT:
- Head: [Normocephalic, atraumatic, scalp lesions]
- Eyes: [PERRLA, EOMI, conjunctiva, sclera, fundoscopy if done]
- Ears: [TMs, canals, hearing]
- Nose: [Nares, septum, discharge, sinus tenderness]
- Throat: [Oropharynx, tonsils, dentition, mucosa]
Neck:
[Supple/stiff, lymphadenopathy, thyroid, JVP, carotid bruits]
Cardiovascular:
- Inspection: [PMI, precordial movement]
- Palpation: [PMI location, thrills, lifts]
- Auscultation: [Rate, rhythm, S1/S2, murmurs/rubs/gallops, location and radiation]
- Peripheral pulses: [Radial, femoral, DP, PT - rate quality bilaterally]
- Extremities: [Edema, cyanosis, clubbing]
Pulmonary:
- Inspection: [Respiratory effort, use of accessory muscles, chest wall deformities]
- Palpation: [Tactile fremitus, chest expansion]
- Percussion: [Resonance, dullness]
- Auscultation: [Breath sounds, adventitious sounds - location and quality]
Abdomen:
- Inspection: [Contour, scars, distention, visible peristalsis]
- Auscultation: [Bowel sounds - present, hyperactive, hypoactive, absent]
- Percussion: [Tympany, dullness, liver span, spleen]
- Palpation: [Soft/firm, tenderness, masses, organomegaly, rebound, guarding, Murphy's sign]
Musculoskeletal:
- Inspection: [Deformities, swelling, erythema]
- Palpation: [Tenderness, warmth]
- Range of motion: [Active and passive, limitations]
- Strength: [5-point scale by major muscle groups]
- Gait: [Normal, antalgic, ataxic, spastic]
Skin:
[Color, temperature, moisture, turgor, lesions, rashes, wounds]
Neurological:
- Mental Status: [Alert, oriented x3 (person, place, time), speech, memory]
- Cranial Nerves: [II-XII - document abnormalities]
- Motor: [Strength 5-point scale, tone, bulk, fasciculations]
- Sensory: [Light touch, pinprick, proprioception, vibration]
- Reflexes: [Deep tendon reflexes 0-4+ scale, Babinski]
- Coordination: [Finger-to-nose, heel-to-shin, rapid alternating movements]
- Gait: [Already documented above or describe here]
Psychiatric:
[Mood, affect, thought process, thought content, judgment, insight]
Genitourinary: (if applicable)
[Defer/document findings if examined]
Rectal: (if applicable)
[Defer/document findings if examined]
Laboratory and Imaging Results
[Include relevant results available at time of H&P]
Labs ([Date]):
| Test | Result | Reference Range | Flag |
|---|---|---|---|
| WBC | [Value] | [Range] | [H/L/-] |
| Hemoglobin | [Value] | [Range] | [H/L/-] |
| [Additional labs] |
Imaging ([Study], [Date]):
[Key findings]
ECG ([Date]):
[Rate, rhythm, intervals, axis, ST-T changes, other findings]
Other Studies:
Assessment and Plan
Assessment:
[Patient summary statement in one sentence]
Problem List:
1. [Primary Problem/Diagnosis] ([ICD-10 code])
Assessment: [Brief description of problem, severity, stability]
Plan:
- Diagnostics: [Labs, imaging, consultations needed]
- Therapeutics: [Medications, procedures, interventions]
- [Medication]: [dose, route, frequency] for [indication]
- Monitoring: [What to monitor, how often]
- Follow-up: [When and with whom]
- Disposition: [Admit to floor/ICU, discharge, observation]
2. [Secondary Problem] ([ICD-10 code])
Assessment: [Description]
Plan:
- [Diagnostics]
- [Therapeutics]
- [Monitoring]
3. [Additional Problems] [Continue for all active problems]
Code Status: [Full code / DNR / DNI / Other]
Prophylaxis:
- DVT prophylaxis: [Pharmacologic and/or mechanical]
- GI prophylaxis: [If indicated]
- Aspiration precautions: [If indicated]
Disposition: [Admit to service, location (floor/ICU), level of care]
Signature
Physician: [Name, credentials]
Level: [Intern, Resident, Attending]
Date/Time: [MM/DD/YYYY at HH:MM]
Signature: ____________________
Co-signature (if applicable):
Attending: [Name, credentials]
Date/Time: [MM/DD/YYYY at HH:MM]
Signature: ____________________
Template Completion Checklist
- Chief complaint documented
- HPI comprehensive (≥4 HPI elements for billing)
- PMH reviewed
- Medications reconciled
- Allergies documented
- ROS performed (≥10 systems for comprehensive)
- Complete physical exam documented (≥8 systems for comprehensive)
- Labs/imaging reviewed
- Assessment and plan for each problem
- Code status documented
- Prophylaxis addressed
- Disposition clear
- Completed within 24 hours of admission (TJC requirement)
- Signed and dated