The History and Physical, often abbreviated as H&P, is the standardized procedure and foundational document created when a patient first engages with a healthcare provider. This structured process systematically gathers a person’s health narrative and current physical status to form the basis of all subsequent medical decisions. The H&P is the starting point for establishing a patient’s medical “story” and is arguably the single most important document in a patient’s record, guiding diagnostic and treatment choices. It serves as a comprehensive baseline assessment before any plan of action is implemented.
Understanding the Medical History Component
The “H” component, the medical history, is entirely subjective data gathered directly from the patient or a family member through a detailed interview. This part begins with the Chief Complaint (CC), a concise statement outlining the primary reason the patient is seeking care, ideally captured in the patient’s own words. The History of Present Illness (HPI) then expands upon the CC, providing a chronological narrative of the current problem from the first symptom to the present day.
A proper HPI utilizes specific characteristics to fully describe the symptoms, including location, quality, severity, timing, setting, and any factors that aggravate or alleviate the discomfort. Following the HPI, the provider documents the Past Medical History (PMH), which includes all previous chronic conditions, surgeries, major illnesses, and injuries. This section also records all current medications, including dosages, and any known allergies, noting the specific type of reaction.
The Family History (FH) records significant health problems in first-degree relatives, such as parents and siblings, to identify potential hereditary risks for conditions like heart disease or certain cancers. Furthermore, the Social History (SH) provides context about the patient’s lifestyle, covering factors like occupation, living situation, diet, exercise habits, and the use of tobacco, alcohol, or other substances. Finally, the Review of Systems (ROS) is a comprehensive, head-to-toe inquiry about symptoms in every major body system, ensuring no related or seemingly unrelated issue is overlooked.
What Happens During the Physical Examination
The “P” component, the physical examination, is the collection of objective data, consisting of measurable and verifiable findings gathered by the clinician. The examination begins with recording the patient’s vital signs: heart rate, blood pressure, respiratory rate, and body temperature. The physical exam relies on a sequence of techniques: inspection, palpation, percussion, and auscultation.
Inspection involves a detailed visual examination of the patient’s appearance, gait, and specific body areas, looking for signs such as skin color changes, symmetry, or swelling. Palpation uses touch to assess for abnormalities like tenderness, masses, texture, temperature, or pulsations beneath the skin or in organs. Percussion involves tapping on the body surface to produce sounds that reflect the density of the underlying structures, helping to identify fluid, air, or solid masses in areas like the lungs or abdomen.
The final technique, auscultation, requires a stethoscope to listen to sounds produced by internal organs, allowing the provider to evaluate the heart rhythm, lung sounds, and bowel activity. The physical examination is then conducted systematically, moving through each body system. This systematic review ensures a complete picture of the patient’s current physical condition is documented.
How the H&P Leads to Diagnosis and Treatment
The H&P is not merely two separate lists; the synthesis of the subjective history and the objective physical findings leads to the clinical conclusion. The provider integrates the patient’s reported symptoms (H) with the measurable observations (P) to formulate the “Assessment.” This Assessment is the clinician’s working diagnosis or a list of differential diagnoses—the most likely conditions that could explain the patient’s presentation.
The Assessment section requires the provider to use clinical reasoning, explaining how specific findings from the history and physical exam either support or refute each potential diagnosis. For example, a patient reporting chest pain (subjective) combined with an irregular heart rhythm noted during auscultation (objective) strongly supports a cardiac diagnosis. This logical justification validates the medical impression.
Following the Assessment is the “Plan,” which outlines the course of action based on the working diagnosis. The Plan includes specific steps for further diagnostic testing, such as blood work or imaging studies, and the immediate and long-term treatment strategy. It also covers patient education, medication prescriptions, and follow-up arrangements, ensuring every element of the Plan is directly justified by the H&P findings.
When and Where the H&P is Used
The H&P is a flexible procedure that varies in depth depending on the patient’s needs and the clinical setting. A Comprehensive H&P is the most detailed version, typically performed during an initial patient encounter, such as a new hospital admission or an annual physical examination. This extensive assessment gathers a complete history and performs a full physical examination across all body systems.
In contrast, a Focused H&P is a shorter, more targeted assessment used for patients presenting with a single, well-defined problem, such as a follow-up visit or an urgent care visit for a sore throat. This focused approach requires a brief history of the current illness and a physical examination limited to the affected body system. H&Ps are utilized across the entire spectrum of healthcare, from inpatient settings to outpatient clinics and emergency departments, serving as the universal standard for patient evaluation.