From the Guidelines
A comprehensive History and Physical Examination template should include chief complaint, history of present illness, past medical history, medications, allergies, family history, social history, review of systems, physical examination findings, assessment, and plan, as outlined in the most recent guidelines 1. The template should begin with patient identifiers (name, age, gender) and the chief complaint in the patient's own words.
Key Components
- The history of present illness should detail symptom onset, duration, severity, exacerbating/alleviating factors, and related symptoms.
- Document all past medical conditions, surgeries, current medications with dosages, and allergies with specific reactions.
- Include relevant family medical history focusing on hereditary conditions.
- Social history should cover occupation, living situation, substance use (tobacco, alcohol, drugs), and relevant social determinants of health.
- The review of systems should methodically address all body systems, as suggested by the American Heart Association 1.
Physical Examination
- Physical examination should be organized by body systems, starting with vital signs and general appearance, then proceeding head-to-toe, including a focused neurological examination for patients with spontaneous intracerebral hemorrhage 1.
- The assessment section should list diagnoses or differential diagnoses in order of importance.
- Finally, the plan should outline diagnostic tests, treatments, medications, patient education, and follow-up arrangements. This structured approach ensures comprehensive documentation, facilitates clinical decision-making, maintains continuity of care, and meets medical-legal requirements while providing a clear clinical picture of the patient's condition, as supported by the American College of Cardiology Foundation/American Heart Association task force on clinical data standards 1.
From the Research
History and Physical Examination Template
The template for a History and Physical Examination (H&P) typically includes the following components:
- Chief complaint
- History of present illness
- Past medical history
- Family history
- Social history
- Review of systems
- Physical examination
Components of the Physical Examination
The physical examination component of the H&P template may include:
- Inspection
- Palpation
- Percussion
- Auscultation
- A head-to-toe assessment, as described in 2
Use of Standardized Templates
Standardized H&P templates can improve clinical documentation and reimbursement, as shown in 3. The use of a dedicated template can help capture important elements, such as review of systems and physical examination, and reduce the likelihood of missing elements.
Examples of Specialized Templates
Specialized H&P templates, such as an asthma-specific template, can improve documentation and care planning, as demonstrated in 4. These templates can include elements specific to the condition, such as asthma severity classification and environmental history.
Importance of History Taking
History taking is a crucial component of the H&P, and a structured approach can help gather relevant information, as outlined in 5. Important communication skills for nurses when taking a history include active listening, empathetic communication, and cultural sensitivity.
Reinvigorating the Clinical Examination
The clinical examination, including the H&P, is essential for diagnosis and management, and efforts to reinvigorate its practice can improve patient care, as discussed in 6. Strategies to promote the clinical examination include being present with the patient, practicing an evidence-based approach, and seeking feedback on physical examination skills.