Understanding the Importance of History and Physical (H&P) in the Medical Field
The History and Physical (H&P) is arguably, the backbone of a patient's medical record. The quality of care a patient receives depends heavily on the medical history a provider takes and any findings discovered during the physical exam. A concise, thorough record of this information can help streamline treatment and provide providers with a good overall picture of a patient's health and needs.
What Is a History and Physical Record?
A History and Physical is a comprehensive formal assessment by a healthcare provider who examines the patient and their presenting problem (typically during an initial visit). The information gathered during this visit includes a thorough health history and a physical exam. The H&P is part of the patient's permanent record and is frequently referenced throughout the course of their treatment by one or more providers. The H&P can be kept in paper-based form but is ideally electronic as part of a patient's EHR (Electronic Health Record).
Why the H&P is Crucial in Quality Care
The H&P must provide a broad yet detailed overview of a patient's medical history and concerns in a concise and easily accessed manner. As evidenced below by the abundance of information collected during the Health and Physical, a patient's treatment plan can be influenced by many different factors. Busy practitioners must make accurate notes during the H&P to ensure they don't leave out important points that could impact the ongoing care of their patients.
The H&P also informs other practitioners who may be working on a case to learn quickly about the patient and their needs.
The Two Parts of the H&P
The H&P consists of two parts. The first is a thorough medical history prompted by questions from the practitioner (and any prior medical records that may have been provided). The second portion is the physical exam, which allows the practitioner to assess the patient's current health and address the chief complaint.
A patient's medical history can help paint a picture of their overall health and guide the practitioner in developing a treatment plan. During the patient interview, the provider will ask questions to understand the patient's past and present symptoms, conditions, and other important information.
These points should include:
Chronic and acute conditions, both past and present
Surgeries or procedures the patient has had
Major illnesses or injuries
All allergies, including those caused by medications, foods, and environmental factors
The names and dosages of medications (prescription and over-the-counter) and supplements currently being taken and for what reason
Medications taken in the past
Lifestyle factors (i.e., dietary and exercise habits; alcohol, drug, and tobacco consumption; etc.)
Family history of diseases and conditions
Results of prior routine tests, such as mammograms, colonoscopies, pap smears, etc.
The physical exam should be thorough and include an assessment of each system. When a practitioner performs a physical exam, they should include:
Vital signs (height, weight, pain scale, temperature, pulse rate, respiration rate, blood pressure, blood oxygen saturation)
Ear, nose, and throat assessment, looking for any abnormalities, including swelling, irritation, discharges, and pain
A chest exam, in which the provider listens to the patient's heart and lungs and makes note of any unusual signs like arrhythmias, wheezing, etc.
The abdominal exam checks for enlarged internal organs, unusual masses, and fluid retention, along with discomfort upon palpation
Neurological and extremities exams will test the function of reflexes, balance, muscle strength, mental acuity, joint function, and appearance
A dermatological assessment will be made, with any suspicious areas noted and referrals to specialists issued if any malignancies are suspected
There are also specific exams for both male and female patients that may be performed by a practitioner or referred out (as is often the case in gynecological matters or urology issues).
SOAP is an acronym used frequently in the medical fields (both human and veterinary) to remind practitioners of the different portions of the H&P they should cover. It's an essential tool during the H&P. SOAP stands for Subjective, Objective, Assessment, and Plan.
The Subjective portion documents how the patient is feeling and what they are experiencing. This is part of the history of an exam.
The Objective part includes tangible observations, such as the patient's appearance, vitals, exam findings, and any lab or other test results, such as ECG readings.
The Assessment should include conclusions drawn from the first two portions of the SOAP exam. This might consist of a preliminary diagnosis or differential diagnosis.
A Plan is the course of action the practitioner believes would benefit the patient most based on their exam findings. All of this must be recorded in the patient's H&P.
The Advantage of the Electronic History and Physical
The traditional pen-and-paper method of developing the History and Physical can be inconsistent and create barriers to finding needed information quickly. For instance, not every practitioner records information in the same order, requiring that the entirety of the H&P findings be skimmed for the required data. It is also not uncommon to forget to note specific facts or findings when working with a paper-based History and Physical.
The advent of the electronic health record has streamlined a once arduous (and potentially error-riddled) process of information gathering and reporting. The EHR H&P contains fields for each aspect of the history and exam. This gives practitioners the freedom to concentrate on listening, observation, examination, and absorbing vital information rather than trying to remember the next step in the H&P process.
NextGen EHR is completely customizable and that includes the History and Physical templates. The TempDev team can help build the perfect solution to not only make documenting a H&P a snap but also the entire patient-provider interaction throughout the patient's treatment. We're happy to discuss any needs a practice may have and create a system that fits the needs of all of its practitioners.
How TempDev Can Help with Document a History and Physical
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