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In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to
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.
Time pressures, an increasing reliance on technology and limited opportunities for bedside teaching have contributed to the demise of the physical exam.
However, most reports start with identifying patient information, such as name, age, and gender. This is usually followed by a description of the chief complaint and a summary of the patients medical history. A review of the physical exams findings will follow, along with the physicians assessment and plan.
The history component of an HP gathers relevant information about the patients history with their current chief complaint. This includes reviewing any pre-existing conditions, past hospitalizations and surgeries, allergies, medications being taken, and family medical history.
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What is the Medical History Form? A medical history form is used to disclose a patients past medical details to healthcare providers, physicians, and dentists. The purpose of the medical history form is to show the physician important information regarding the patients health.
A personal history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams, tests, and screenings. It may also include information about medicines taken and health habits, such as diet and exercise.

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