A history and physical, or H+P for short, is a document that will paint how a patient presents to the hospital. If a patient is a re-admit to the hospital, a physician can look at previous H+Ps to determine if a patient’s presentation was like their current presentation. With electronic medical records on the rise, many hospitals can share notes with other institutions without faxing documents. Why is this important? This means your documentation reflects you and the institution you are working for. In addition, it is helpful when a physician appropriately documents because it can help prevent duplicate work-ups, bettering patient care, and save healthcare dollars.
Chief Complaint (CC)
A big mistake I see interns make is not acknowledging the chief complaint. We are here to help the patient: If the physician works up an entirely different problem unrelated to the chief complaint that the patient initially presented with, then that physician has not done their job correctly. Always listen to the patient because this will provide you with most of your information to crack down on your diagnosis.
History of Present Illness (HPI)
The HPI is where the physician will document the details of the patient’s chief complaint. In school, I was taught the mnemonic OLD CARS; please see below.
- O – Onset
- L – Location
- D – Duration
- C – Characterization
- A – Aggravating factors
- R – Relieving factors
- S – Symptoms
This mnemonic is excellent when you do not know where to start. You can collect enough information, and it will be organized and detailed. That said, when a patient speaks to you, going in an exact order sometimes is not feasible. But do not despair, this is normal, and patients are not robots. Additionally, most patients do not understand that physicians collect information in a specific way, so you may find that you must redirect your questions.
Side note: I struggled with the above-stated concept because of my Type A personality. I did not realize that real life differs from the books and what you learned. Eventually, you will find your groove, but it does take time. Do not be frustrated.
Past History
Medical History
Sometimes patients will tell you that they do not have a medical history, only for a physician to find out that the patient is taking multiple medications.
One way I phrase this question is “what type of medical problems do you have, for example, hypertension, diabetes, high cholesterol, etc.” Sometimes this helps prompt the patient to understand what data you are trying to extract from them.
Surgical History
It is important to be direct and observant when asking about a patient’s surgical history. Sometimes the patient forgets about surgeries because they might have occurred over two decades ago.
Side note: I once had a patient who claimed that he had no surgeries and come to find out he had a large linear scar on his anterior chest wall, and he forgot that he had a sternotomy with an aortic and mitral valve replacement.
You want to find out what surgery it was when it was, and if there were any complications. Example
Example: Right inguinal hernia repair – 2012 – no complications
Medications
With medications, you want to ask the following,
- Name of medication
- Dosage
- Frequency
- Reason
- Sometimes ask who the prescriber is
Side note: I think it is important to know where a patient is obtaining their prescriptions from. Sometimes you will find that the patient is getting the prescription from a friend or family member. This can be dangerous for the patient and is an opportunity to educate the patient on the importance of following up with a healthcare provider.
Allergies
Ask the patient if they have any known allergies or drug allergies. If the patient states yes, please ask them to specify their reaction. A lot of times a patient might state they are allergic to a medication, but they are experiencing an adverse side effect of the medication.
Examples:
- Penicillin – Anaphylactic shock (This is a true allergy)
- Morphine – “upsets my stomach” (This is not an allergy)
Family History
This is especially important in primary care as many guidelines are based on diseases within 1st-degree relatives. This information is also useful for risk stratification, which can determine if someone is admitted to the hospital.
Social History
The mnemonic FEDTACOS is helpful when trying to recall relevant social history.
- F – Food
- E – Exercise
- D – Drugs
- T – Tobacco (cigarettes, cigars, vaping, etc.)
- A – Alcohol
- C – Caffeine intake
- O – Occupation
- S – Sexual history
Sometimes asking these questions may not feel relevant, but when piecing all the items together, a physician can paint a story of why and how a patient requires hospitalization.
Review of Systems (ROS)
This section is really for “anything else.” I like to add many of these questions to my HPI if they are relevant. When a physician becomes more experienced, they can obtain a focused ROS.
Side note: When obtaining the history from the patient, one can decide to ask the history questions in reverse order (social history, family history, allergies, medications, surgical history, and medical history). As I mentioned previously, many patients will not be able to recall their past medical history unless prompted by their medication list.
Objective
This section is self-explanatory. This is the section that is data-driven based. There should be no statements, opinions, or assessments in this section.
- Vitals
- Vitals are the ones you recorded in the presentation.
- Physical Exam
- This section should be complete, accurate, and honest in examining the patient.
- Labs
- Imaging
Assessment and Plan
Please see my post on “How to Write a Progress Note” to effectively execute this section. Aside from the HPI, the assessment and plan are among the most critical areas to master in the documentation.
A Medical Blog by Dr. Megan Arielle 