What are the steps to write a complete History and Physical (H&P)?

How to Write a Complete History and Physical (H&P)

A complete History and Physical (H&P) should include a thorough history, comprehensive physical examination, assessment, and plan, with the history section being the cornerstone of the diagnostic process. 1

Components of a Complete H&P

1. Patient Demographics

• Include name, date of birth, gender, ethnicity/race, and other identifying information 1
• Document primary language, years of education, occupation, and living situation 1

2. Chief Complaint (CC)

• Document the patient's main concern in their own words 1
• Keep this brief and focused on the primary reason for the visit 1

3. History of Present Illness (HPI)

• Provide a chronological narrative of the current illness or complaint 1, 2
• Include the following elements:
  • Onset (when symptoms began) 1
  • Quality (characteristics of symptoms) 1
  • Intensity/severity of symptoms 1
  • Distribution (location and radiation) 1
  • Duration and course of symptoms 1
  • Exacerbating and relieving factors 1
  • Sensory and affective components 1
  • Associated symptoms (motor, sensory, autonomic changes) 1
  • Previous diagnostic tests and results 1
  • Previous and current therapies 1

4. Past Medical History

• Document all medical conditions 1
• Include cardiovascular diseases (MI, arrhythmias, heart failure) 1
• Document cerebrovascular diseases (stroke, TIA) 1
• Include other chronic conditions (hypertension, diabetes, thyroid disorders) 1
• Document previous surgeries and procedures 1

5. Medication History

• List all current medications with dosages and frequencies 1
• Include over-the-counter medications and supplements 1
• Document medication allergies and adverse reactions 1

6. Family History

• Document diseases in first-degree relatives 1
• Focus on relevant hereditary conditions 1
• For cardiac patients, obtain a 3-generation family history to identify possible inherited disease 1

7. Social History

• Document tobacco, alcohol, and substance use 1
• Include occupational exposures and living situation 1
• Document marital status and support systems 1
• Note relevant lifestyle factors (diet, exercise) 1

8. Review of Systems (ROS)

• Systematically review each body system 1
• Document both positive and pertinent negative findings 1
• Include at minimum:
  • Constitutional symptoms (fever, weight changes)
  • Head, eyes, ears, nose, throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/lymphatic
  • Allergic/immunologic

9. Physical Examination

• Document vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation) 1
• Perform a targeted examination based on the presenting complaint 1
• Include general appearance and mental status 1
• Document findings from each relevant body system 1
• For cardiac patients, assess volume status, including jugular venous pressure and presence of peripheral edema 1

10. Laboratory and Diagnostic Data

• Document relevant laboratory results 1
• Include imaging findings and other diagnostic test results 1
• Note any pending studies 1

11. Assessment and Plan

• Provide a concise summary of the patient's condition 1
• List differential diagnoses in order of likelihood 3
• Document clinical reasoning supporting the assessment 3
• Outline the diagnostic and treatment plan 1
• Include patient education and follow-up plans 1

Common Pitfalls and How to Avoid Them

• Disorganized HPI: Use a chronological approach to organize the HPI, which improves diagnostic reasoning 2
• Incomplete medication history: Always document both prescription and over-the-counter medications 1
• Missing family history: For patients with suspected genetic conditions, obtain a multi-generational family history 1
• Inadequate physical examination: Perform a targeted physical exam based on the presenting complaint rather than a generic examination 1
• Failure to document clinical reasoning: Clearly articulate your thought process in the assessment section 3
• Overlooking psychosocial factors: Include a psychosocial evaluation that assesses the impact of the condition on the patient's daily life 1

Special Considerations for Specific Patient Populations

• Cardiac patients: Focus on volume status assessment and a 3-generation family history 1
• Neurological patients: Include detailed cognitive and functional assessments 1
• Pain management: Document pain characteristics thoroughly and include psychosocial evaluation 1
• Elderly patients: Pay special attention to functional status, cognitive assessment, and medication review 1

By following this structured approach to the H&P, you will create a comprehensive document that serves as both a diagnostic tool and a foundation for the patient's medical record 4, 5.