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The HP must contain sufficient information to support the diagnosis or differential diagnosis, justify the treatment plan, and facilitate the care after discharge. 6. The HP must be legible and documented in a manner so as to be durable and permanent.
What is a history and physical form?
The HP: History and Physical is the most formal and complete assessment of the patient and the problem. HP is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.
What is a focused history and physical examination?
FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL During this phase of the patient assessment, the mnemonic OPQRST and SAMPLE will be used to gather information about the chief complaint and history of the present illness. Baseline vital signs and a focused physical exam or a rapid medical assessment will be performed.
What is the difference between a SOAP note and a history and physical?
SOAP NOTE. A SOAP note is different from an HP because it is problem specific. A SOAP note can be useful because it helps you organize all the subjective and objective information about a problem in one place.
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PURPOSE: The information solicited from this form will assist in making a medical clearance decision for individuals eligible to participate in the. Department
History Physical Format. SUBJECTIVE (History). Identification name, address, tel.#, DOB, informant, referring provider. CC (chief complaint) list of symptoms
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