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History and physical template

History and physical template 2025

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The document is an Initial Clinical History and Physical Form used to collect comprehensive patient information, including personal details, medical history, surgical history, medications, social habits, family history, and specific health screenings. It serves as a foundational tool for healthcare providers to assess a patient's health status and needs during their visit.

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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 are the requirements of a history and physical?

The H P must include a chief complaint, history of present illness, a review of systems, past surgical history, family history, social history, medication list, allergies, and results of a physical examination including vital signs.

How to write a history and Physical?

The HPI should be written in prose with full sentences and be a narrative that builds an argument for the reason the patient was admitted. Has a starting point (i.e. the patient was in her usual state of health until 5 days prior to admission.). Has appropriate flow, continuity, sequence, and chronologic order.

Why is history and physical important in diagnosis?

A patients health history is a key factor in timely and accurate diagnosis of acute illness and leads to improved outcomes. A thorough social and environmental health history can be just as informative as the physical examination and clinical diagnostics in the diagnosis and prompt treatment of illness.

What is included in a history and physical note?

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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