The Comprehensive History & Physical Exam
•Documents the patient's medical history, physical exam findings, diagnoses or medical problems,
diagnostic studies to be performed, and initial plan of care implemented to add
...
The Comprehensive History & Physical Exam
•Documents the patient's medical history, physical exam findings, diagnoses or medical problems,
diagnostic studies to be performed, and initial plan of care implemented to address any problems
identified.
•Do not copy another provider's H&P- always perform your own and if unable to then give credit to
the provider responsible
•History includes: patient's personal identification
•Chief Complaint (CC)- why is the patient there? (Best stated in the patient's own words)
•History of the Present Illness or History of the CC: the chronological description of the development
of the patient's present illness from the first sign or symptom of the presenting problems. Include
identifying elements such as location, quality, severity, duration, timing, content, modifying factors,
& associated sign and symptoms.
•Past Medical History: documents the patient's past and current health. Includes: Past medical
history, past surgical history or other hospitalizations (provide dates if possible), medications, drug
allergies, and health maintenance and immunizations.
•Family History: first-degree relatives includes parents, grandparents, and siblings with the age their
age and status. If deceased, include the age at time of death and cause of death.
Psychosocial History: Identify factors that may influence the patient's overall health or behaviors that
places the patient at risk for specific conditions. Includes patient's sexual orientation, marital status,
children, occupation status, environmental risks, language preference (if interpreter required, it
must be documented), religion/ cultural beliefs, tobacco/etoh/illicit drug use, diet, etc.
• Review of Systems (ROS): an inventory of specific body systems designed to document any
symptoms the patient may be experiencing or has experienced. Includes positive and negative
responses from patient
• Physical Examination: may confirm or refute a diagnosis suspected from the history and
provide a more accurate problem list.
• Laboratory & Diagnostic Studies: laboratory tests, radiographs, or other imaging studies with
specific values/results which allows readers to formulate their own conclusions, documents baseline
values, and saves time for other readers to look values.
• Problem List, Assessment, and Differential Diagnosis: provider evaluates all the info to
identify the patient's problems in a numbered list (includes date of onset and whether
active/inactive) with the most severe problems listed first.
• Plan of Care: document any additional studies or workup needed, referrals or consults
needed, pharmacological management, nonpharm.or other management patient education, and
disposition (i.e., "return to clinic" or "admit to the hospital"
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