History and Physical (H&P) Template

What Is a History and Physical (H&P)?

The History and Physical, commonly abbreviated H&P, is the foundational clinical document completed when a patient is admitted to the hospital or seen for an initial consultation. It is the most comprehensive note a physician writes — a complete portrait of the patient at a single point in time that includes their presenting complaint, full medical background, physical examination findings, and the clinician's initial assessment and plan.

The H&P serves multiple purposes simultaneously. It is a clinical reasoning tool that forces structured diagnostic thinking. It is a legal document that records the basis for medical decisions. It is a communication instrument that informs every subsequent provider. And it is a billing document that supports the level of service rendered. Getting it right matters.

Who Uses This Template?

• Hospitalists and internists admitting patients to the medical service
• Surgeons performing preoperative assessments
• Medical residents and students completing admission H&Ps on teaching services
• Specialists documenting initial consultations
• Emergency physicians writing comprehensive evaluations for admitted patients

Template

Patient Identification

• Patient name, date of birth, age, sex, medical record number
• Date and time of examination
• Source of history (patient, family member, EMS, outside records)
• Reliability of historian

Chief Complaint (CC)

A single sentence in the patient's own words (or the referral reason).

• Example: "Worst headache of my life since this morning."
• Example: "Admitted from the ED for management of diabetic ketoacidosis."

History of Present Illness (HPI)

The HPI is the most important section of the H&P. Construct a chronological narrative that leads the reader from the onset of symptoms to the present moment.

Structure your HPI to include:

1. Patient identifier and context — age, sex, relevant PMH in a brief opening line
2. Symptom onset and timeline — when it started, how it has evolved
3. Symptom characterization — quality, severity, location, radiation
4. Modifying factors — what makes it better or worse
5. Associated symptoms — positives and negatives that narrow the differential
6. Prior evaluation — ED workup, outside hospital records, self-treatment
7. Current status — how the patient feels right now

Example: "Mr. David Park is a 45-year-old male with no significant past medical history who presents with sudden onset of severe headache beginning at 7:00 AM today. He was lifting weights at the gym when he experienced what he describes as a thunderclap headache — maximal intensity within seconds, rated 10/10, located in the occipital region with radiation to the neck. He had one episode of vomiting. He denies photophobia, neck stiffness, focal weakness, numbness, visual changes, or loss of consciousness. He took ibuprofen 600 mg without relief. His wife drove him to the ED where a noncontrast CT head was performed and read as negative for hemorrhage. He was referred for admission for further evaluation including lumbar puncture to rule out subarachnoid hemorrhage. Currently, he rates his headache at 8/10."

Review of Systems (ROS)

A systematic survey beyond the HPI. Document at least 10 systems for a comprehensive H&P. Note pertinent positives and negatives.

• Constitutional: No fever, chills, night sweats, or unintentional weight change.
• HEENT: No visual changes, eye pain, hearing loss, tinnitus, sore throat, or nasal congestion.
• Cardiovascular: No chest pain, palpitations, orthopnea, PND, or lower-extremity edema.
• Respiratory: No cough, dyspnea, wheezing, or hemoptysis.
• Gastrointestinal: One episode of vomiting (noted in HPI). No abdominal pain, diarrhea, constipation, melena, or hematochezia.
• Genitourinary: No dysuria, hematuria, or urinary frequency.
• Musculoskeletal: No joint pain, swelling, or back pain.
• Neurological: No focal weakness, numbness, tingling, gait difficulty, seizures, or syncope. Positive for severe headache (noted in HPI).
• Psychiatric: No depression, anxiety, or suicidal ideation.
• Skin: No rashes, bruising, or petechiae.
• Hematologic/Lymphatic: No easy bruising or bleeding, no lymphadenopathy.
• Endocrine: No polyuria, polydipsia, heat or cold intolerance.

Past Medical History (PMH)

• Active medical diagnoses (with year of diagnosis when known)
• Chronic conditions and disease status
• Example: "No significant past medical history. No prior hospitalizations."

Past Surgical History (PSH)

• All prior surgeries with approximate dates
• Example: "Appendectomy (2008). No other surgeries."

Medications

• List all current medications with dose, route, and frequency
• Include OTC medications, supplements, and herbal products
• Example: "No daily medications. Takes ibuprofen 400–600 mg PRN for muscle soreness."

Allergies

• Drug allergies with reaction type
• Example: "NKDA (no known drug allergies)."

Family History (FH)

• First-degree relatives: major medical conditions, cause of death, age at death
• Hereditary conditions relevant to the chief complaint
• Example: "Father alive, age 72, hypertension. Mother alive, age 68, type 2 diabetes. One sibling, healthy. No family history of aneurysm, stroke, or sudden death."

Social History (SH)

• Tobacco: Current, former, or never. Quantify in pack-years.
• Alcohol: Frequency and quantity.
• Substances: Any recreational or illicit drug use.
• Occupation: Current job and relevant exposures.
• Living situation: Who the patient lives with, support system.
• Exercise and diet: Activity level and dietary patterns.
• Advance directives: Code status, healthcare proxy if relevant to the admission.

Example: "Never smoker. Drinks 2–3 beers on weekends. Denies illicit drug use. Works as a software engineer. Lives with wife and two children. Exercises 4 days per week (weightlifting and running). Full code. No advance directives on file."

Physical Examination

Perform and document a comprehensive exam. Be specific — "normal" is not a finding.

• Vitals: BP 142/88 mmHg, HR 78 bpm regular, RR 14, Temp 98.6 F (oral), SpO2 99% on room air.
• General: Alert, oriented x 4, lying in bed with lights off, appears uncomfortable but in no acute distress.
• HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light, 3 mm bilaterally. No papilledema on fundoscopic exam. Oropharynx clear and moist. No facial asymmetry.
• Neck: Supple. No nuchal rigidity (though patient reports subjective neck stiffness). No lymphadenopathy. No carotid bruits. No thyromegaly.
• Cardiovascular: Regular rate and rhythm. S1, S2 normal. No murmurs, gallops, or rubs. No JVD. Peripheral pulses 2+ bilaterally.
• Respiratory: Clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. Symmetric chest expansion.
• Abdomen: Soft, nontender, nondistended. Normal bowel sounds in all four quadrants. No organomegaly.
• Extremities: No edema, cyanosis, or clubbing. Warm and well-perfused.
• Neurological: Cranial nerves II–XII intact. Strength 5/5 in all extremities. Sensation intact to light touch throughout. Deep tendon reflexes 2+ and symmetric. Finger-to-nose intact bilaterally. Gait steady (assessed in ED). Kernig sign negative. Brudzinski sign negative.
• Skin: No rashes, petechiae, or purpura.

Diagnostic Data

Include lab values, imaging, ECG, and any other test results available at admission.

• CT head without contrast (today): No acute intracranial hemorrhage. No mass, midline shift, or hydrocephalus.
• CBC: WBC 8.2, Hgb 15.1, Plt 245. Normal differential.
• BMP: Na 140, K 4.1, Cl 102, CO2 24, BUN 14, Cr 0.9, Glucose 98.
• Coagulation: PT 12.1, INR 1.0, PTT 28.

Assessment

Synthesize the data into a clinical impression. State the most likely diagnosis, the differential, and your reasoning.

Example: "Mr. Park is a 45-year-old previously healthy male presenting with sudden-onset thunderclap headache maximal at onset, concerning for subarachnoid hemorrhage (SAH). Although the noncontrast CT head is negative, CT sensitivity for SAH decreases after the first 6 hours, and his presentation is classic. Lumbar puncture is indicated to evaluate for xanthochromia. Differential also includes primary thunderclap headache, reversible cerebral vasoconstriction syndrome (RCVS), and cerebral venous sinus thrombosis, though the latter two are less likely given the absence of focal deficits and risk factors."

Plan

Organize by problem. Include diagnostics, therapeutics, monitoring, and disposition considerations.

Problem 1: Thunderclap headache — rule out SAH

• Lumbar puncture: send CSF for cell count, protein, glucose, xanthochromia (tubes 1 and 4 for RBC comparison)
• If LP positive for xanthochromia: CT angiography of the head to identify aneurysm
• If LP negative: consider CTA or MRA to evaluate for RCVS given the clinical history
• Analgesia: morphine 2–4 mg IV q4h PRN for severe headache. Avoid NSAIDs until SAH excluded.
• Neuro checks q4h
• Neurosurgery on standby if aneurysm identified

Problem 2: Hypertension (new finding)

• BP 142/88 — may be pain-related. Recheck after analgesia.
• No antihypertensives at this time. Monitor.

Disposition: Admit to medicine, telemetry. Neurosurgery consultation pending LP results.

Common H&P Mistakes

1. Copying a prior note — An H&P should be written fresh. Copy-forward errors are dangerous and detectable on audit.
2. Incomplete ROS — Billing for a comprehensive H&P requires documentation of at least 10 organ systems.
3. Physical exam by template only — "WNL" (within normal limits) for every system suggests the exam was not actually performed. Document real findings.
4. Burying the clinical reasoning — The Assessment should make your thought process transparent. A list of diagnoses without explanation is insufficient.
5. Vague plan — "Will work up headache" is not a plan. Specify the tests, the sequence, and the decision points.

Automate Your H&P Documentation

The admission H&P is one of the most time-consuming documents in medicine, often written after a long day of patient care. NotuDocs helps physicians generate comprehensive H&P notes from recorded encounters and clinical data — so you verify and refine instead of writing from memory at 2 AM.