The H&P, or the “History and Physical,” is a term used to describe a physician’s examination of a patient.
In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings. The H&P is seen as an essential part of patient care and guides later diagnostic and treatment decisions.
H&P: The History Component
The history component of an H&P gathers relevant information about the patient’s 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.
H&P: The Physical Component
The physical component of an H&P is a standard physical exam, and the physician will measure vital signs such as blood pressure, heart rate, respiration, and oxygen levels. This next step is inspecting the patient’s eyes, ears, nose, throat, abdomen, skin, and extremities.
How the H&P Is Reported
There is no standard format for History and Physical reports. 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 patient’s medical history.
A review of the physical exam’s findings will follow, along with the physician’s assessment and plan.
Some electronic medical record systems will guide the physician through information to collect for an H&P and then generate the report.
How TempDev Can Help With H&P Reports
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