History and Physical Examination (H&P) Template

Patient Name: [Last, First]
Medical Record Number: [MRN]
Date of Birth: [MM/DD/YYYY]
Age: [years]
Sex: [M/F]

Date of Admission/Encounter: [MM/DD/YYYY]
Time: [HH:MM]
Location: [Hospital floor, Clinic, ED]
Admitting Service: [Medicine, Surgery, etc.]
Attending Physician: [Name]

---

Chief Complaint (CC)

"[Patient's stated reason for seeking care, in quotes]"

---

History of Present Illness (HPI)

[Patient Name] is a [age]-year-old [sex] with a history of [relevant PMHx] who presents with [chief complaint].

[Use OPQRST format for symptoms, provide chronological narrative]

Onset: [When did symptoms start? Sudden vs gradual onset?]
Location: [Where? Does it radiate?]
Duration: [How long?]
Character: [Quality - sharp, dull, pressure, etc.]
Aggravating factors: [What makes it worse?]
Relieving factors: [What makes it better?]
Timing: [Constant or intermittent? Pattern?]
Severity: [0-10 scale for pain, functional impact]
Associated symptoms: [Other symptoms?]

Prior evaluations and treatments:
Why presenting now:

---

Past Medical History (PMH)

1. [Condition] - diagnosed [year], [current status]
2. [Condition] - diagnosed [year], [treatment]
3. [Additional conditions]

[ ] No known medical problems

---

Past Surgical History (PSH)

1. [Procedure] ([year]) - [indication, complications if any]
2. [Procedure] ([year])

[ ] No prior surgeries

---

Medications

Medication	Dose	Route	Frequency	Indication
[Drug name]	[mg]	[PO/IV/etc]	[BID/etc]	[Why prescribed]

[ ] No current medications

---

Allergies

Allergen	Reaction
[Drug/Food/Environmental]	[Type of reaction]

[ ] No known drug allergies (NKDA)

---

Family History (FH)

• Father: [Age/deceased at age X], [medical conditions]
• Mother: [Age/deceased at age X], [medical conditions]
• Siblings: [Number], [relevant conditions]
• Children: [Number], [relevant conditions]

[Note hereditary conditions relevant to patient's presentation]

[ ] Non-contributory

---

Social History (SH)

Tobacco: [Current/former/never], [pack-years if applicable]
Alcohol: [Frequency and amount, CAGE questions if indicated]
Illicit drugs: [Current/former/never, type, route]
Occupation: [Current or former occupation]
Living situation: [Lives alone/with family, housing type]
Marital status: [Single/married/divorced/widowed]
Sexual history: [If relevant]
Exercise: [Type and frequency]
Diet: [General diet description]
Functional status: [ADL independence, baseline activity level]

---

Review of Systems (ROS)

[Systematic review - check relevant systems]

Constitutional: [ ] Fever [ ] Chills [ ] Night sweats [ ] Weight loss [ ] Weight gain [ ] Fatigue
Eyes: [ ] Vision changes [ ] Eye pain [ ] Discharge
ENT: [ ] Hearing loss [ ] Tinnitus [ ] Sinus problems [ ] Sore throat
Cardiovascular: [ ] Chest pain [ ] Palpitations [ ] Edema [ ] Orthopnea [ ] PND [ ] Claudication
Respiratory: [ ] Dyspnea [ ] Cough [ ] Wheezing [ ] Hemoptysis
Gastrointestinal: [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ] Abdominal pain [ ] Melena [ ] Hematochezia
Genitourinary: [ ] Dysuria [ ] Frequency [ ] Urgency [ ] Hematuria [ ] Incontinence
Musculoskeletal: [ ] Joint pain [ ] Swelling [ ] Stiffness [ ] Back pain [ ] Weakness
Skin: [ ] Rash [ ] Lesions [ ] Itching [ ] Changes in moles
Neurological: [ ] Headache [ ] Dizziness [ ] Syncope [ ] Seizures [ ] Weakness [ ] Numbness [ ] Tingling
Psychiatric: [ ] Depression [ ] Anxiety [ ] Sleep disturbance
Endocrine: [ ] Heat/cold intolerance [ ] Polyuria [ ] Polydipsia [ ] Polyphagia
Hematologic/Lymphatic: [ ] Easy bruising [ ] Bleeding [ ] Lymph node swelling
Allergic/Immunologic: [ ] Seasonal allergies [ ] Frequent infections

All other systems reviewed and negative [ ]

---

Physical Examination

Vital Signs:

• Temperature: _____ °F (oral/axillary/tympanic)
• Blood Pressure: / mmHg ([right arm, sitting])
• Heart Rate: _____ bpm (regular/irregular)
• Respiratory Rate: _____ breaths/min
• Oxygen Saturation: _____% on [room air / O2 at ___ L/min]
• Height: _____ cm / inches
• Weight: _____ kg / lbs
• BMI: _____ kg/m²
• Pain Score: ___/10

General:
[Overall appearance, apparent vs stated age, nutritional status, distress level]

HEENT:

• Head: [Normocephalic, atraumatic, scalp lesions]
• Eyes: [PERRLA, EOMI, conjunctiva, sclera, fundoscopy if done]
• Ears: [TMs, canals, hearing]
• Nose: [Nares, septum, discharge, sinus tenderness]
• Throat: [Oropharynx, tonsils, dentition, mucosa]

Neck:
[Supple/stiff, lymphadenopathy, thyroid, JVP, carotid bruits]

Cardiovascular:

• Inspection: [PMI, precordial movement]
• Palpation: [PMI location, thrills, lifts]
• Auscultation: [Rate, rhythm, S1/S2, murmurs/rubs/gallops, location and radiation]
• Peripheral pulses: [Radial, femoral, DP, PT - rate quality bilaterally]
• Extremities: [Edema, cyanosis, clubbing]

Pulmonary:

• Inspection: [Respiratory effort, use of accessory muscles, chest wall deformities]
• Palpation: [Tactile fremitus, chest expansion]
• Percussion: [Resonance, dullness]
• Auscultation: [Breath sounds, adventitious sounds - location and quality]

Abdomen:

• Inspection: [Contour, scars, distention, visible peristalsis]
• Auscultation: [Bowel sounds - present, hyperactive, hypoactive, absent]
• Percussion: [Tympany, dullness, liver span, spleen]
• Palpation: [Soft/firm, tenderness, masses, organomegaly, rebound, guarding, Murphy's sign]

Musculoskeletal:

• Inspection: [Deformities, swelling, erythema]
• Palpation: [Tenderness, warmth]
• Range of motion: [Active and passive, limitations]
• Strength: [5-point scale by major muscle groups]
• Gait: [Normal, antalgic, ataxic, spastic]

Skin:
[Color, temperature, moisture, turgor, lesions, rashes, wounds]

Neurological:

• Mental Status: [Alert, oriented x3 (person, place, time), speech, memory]
• Cranial Nerves: [II-XII - document abnormalities]
• Motor: [Strength 5-point scale, tone, bulk, fasciculations]
• Sensory: [Light touch, pinprick, proprioception, vibration]
• Reflexes: [Deep tendon reflexes 0-4+ scale, Babinski]
• Coordination: [Finger-to-nose, heel-to-shin, rapid alternating movements]
• Gait: [Already documented above or describe here]

Psychiatric:
[Mood, affect, thought process, thought content, judgment, insight]

Genitourinary: (if applicable)
[Defer/document findings if examined]

Rectal: (if applicable)
[Defer/document findings if examined]

---

Laboratory and Imaging Results

[Include relevant results available at time of H&P]

Labs ([Date]):

Test	Result	Reference Range	Flag
WBC	[Value]	[Range]	[H/L/-]
Hemoglobin	[Value]	[Range]	[H/L/-]
[Additional labs]

Imaging ([Study], [Date]):
[Key findings]

ECG ([Date]):
[Rate, rhythm, intervals, axis, ST-T changes, other findings]

Other Studies:

---

Assessment and Plan

Assessment:

[Patient summary statement in one sentence]

Problem List:

1. [Primary Problem/Diagnosis] ([ICD-10 code])

Assessment: [Brief description of problem, severity, stability]

Plan:

• Diagnostics: [Labs, imaging, consultations needed]
• Therapeutics: [Medications, procedures, interventions]
  • [Medication]: [dose, route, frequency] for [indication]
• Monitoring: [What to monitor, how often]
• Follow-up: [When and with whom]
• Disposition: [Admit to floor/ICU, discharge, observation]

2. [Secondary Problem] ([ICD-10 code])

Assessment: [Description]

Plan:

• [Diagnostics]
• [Therapeutics]
• [Monitoring]

3. [Additional Problems] [Continue for all active problems]

Code Status: [Full code / DNR / DNI / Other]

Prophylaxis:

• DVT prophylaxis: [Pharmacologic and/or mechanical]
• GI prophylaxis: [If indicated]
• Aspiration precautions: [If indicated]

Disposition: [Admit to service, location (floor/ICU), level of care]

---

Signature

Physician: [Name, credentials]
Level: [Intern, Resident, Attending]
Date/Time: [MM/DD/YYYY at HH:MM]
Signature: ____________________

Co-signature (if applicable):
Attending: [Name, credentials]
Date/Time: [MM/DD/YYYY at HH:MM]
Signature: ____________________

---

Template Completion Checklist

• Chief complaint documented
• HPI comprehensive (≥4 HPI elements for billing)
• PMH reviewed
• Medications reconciled
• Allergies documented
• ROS performed (≥10 systems for comprehensive)
• Complete physical exam documented (≥8 systems for comprehensive)
• Labs/imaging reviewed
• Assessment and plan for each problem
• Code status documented
• Prophylaxis addressed
• Disposition clear
• Completed within 24 hours of admission (TJC requirement)
• Signed and dated