The History and Physical (H&P) is the foundational document used by healthcare providers to perform a comprehensive initial evaluation of a patient. This assessment offers a complete picture of their current health status and guides all subsequent diagnostic and treatment decisions. It serves as a means of communication, ensuring that all providers involved in the patient’s care have access to the same organized set of information at the time of admission or initial visit. This standardized documentation is critical for streamlining treatment and establishing the framework for understanding the patient’s condition.
Gathering the Patient’s Medical History
The history component of the H&P is the collection of subjective data reported directly by the patient about their symptoms and past experiences. This section begins with the Chief Complaint (CC), a concise, one-sentence statement summarizing the primary reason the patient is seeking care. Following the CC is the History of Present Illness (HPI), which provides a detailed narrative of the current symptoms in a chronological order. The HPI characterizes the symptoms, detailing their onset, location, quality, severity, duration, and any associated factors.
The Past Medical History (PMH) documents all prior health conditions, including chronic diseases, past surgeries, hospitalizations, and major childhood illnesses. This section also includes a comprehensive list of all current medications, along with any known allergies and adverse reactions. A thorough Review of Systems (ROS) is then performed, which is a systematic, head-to-toe inventory of symptoms across all major body systems. The ROS is designed to uncover any symptoms the patient may not have mentioned in the HPI but that could be relevant to the overall clinical picture.
The Social History (SH) provides context about the patient’s lifestyle and environment, documenting details such as occupation, living situation, use of tobacco, alcohol, or illicit substances, and their sexual history. This information can reveal risk factors that influence the patient’s condition or ability to follow a treatment plan. Finally, the Family History (FH) records the health status of immediate blood relatives, noting the age and cause of death for deceased family members. Attention is paid to hereditary conditions like cancer, diabetes, and heart disease, which may indicate a genetic predisposition for the patient’s health risks.
Performing the Physical Examination
The physical examination component of the H&P is where the healthcare provider gathers objective data through direct observation and manipulation of the patient’s body. This process begins with recording the patient’s vital signs, including heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation. The provider then performs a general survey, making a note of the patient’s overall appearance, mental status, and nutritional state.
The examination follows a systematic, head-to-toe approach, reviewing each body system for signs of disease or injury. Four standard techniques are employed: inspection, palpation, percussion, and auscultation.
- Inspection involves visually examining the patient for abnormalities, such as swelling.
- Palpation uses touch to feel for masses, tenderness, or organ size.
- Percussion involves tapping specific areas to assess underlying structures.
- Auscultation is the act of listening to internal sounds, often with a stethoscope, to evaluate the heart, lungs, and abdomen.
Findings are documented by system, such as cardiovascular, pulmonary, neurological, and abdominal, to ensure a comprehensive review. For example, the cardiac exam includes auscultating heart sounds for murmurs, while the pulmonary exam assesses breath sounds and checks for adventitious sounds like wheezes or crackles. The objective data collected provides measurable evidence that either supports or refutes the subjective complaints provided in the history.
Synthesizing Findings into an Assessment and Plan
The final stage of the H&P involves synthesizing the subjective history and the objective physical findings into a clinical conclusion. The Assessment section begins with a concise summary of the patient’s problem and then presents the provider’s working diagnosis or a list of differential diagnoses. This section links the most pertinent findings from the history and physical exam to support the most likely diagnosis. For patients with multiple health issues, the problems are prioritized based on urgency and severity, and each receives its own focused assessment.
The Plan section outlines the next steps for the patient’s care, corresponding to the issues raised in the assessment. This segment includes orders for further diagnostic studies, such as laboratory tests or imaging scans, to confirm the diagnosis or rule out other possibilities. It also details therapeutic interventions, including medications, procedures, patient education, and consultations with specialists. The H&P document is required documentation for legal and regulatory purposes, serving as the official record that justifies the necessity of the patient’s care for billing.