See an example of a complete H&P write-up. The details and
length of a written H&P can vary with the particular problem
and with the service to which the patient is admitted.
- Identification: Name, age,
sex, referring physician, informant (eg, patient, relative, old
chart), and reliability of the informant.
- Chief Complaint: State, in patient’s
words, the current problem.
- History of the Present Illness (HPI): Define
the present illness by quality; quantity; setting; anatomic location
and radiation; time course, including when the illness began; whether
the complaint is progressing, regressing, or steady; whether the
complaint is of constant or intermittent frequency; and aggravating,
alleviating, and associated factors. The information should be in
chronologic order, including diagnostic tests done before admission.
Record related history, including previous treatment for the problem, risk
factors, and pertinent negative results. Include family history
and psychosocial history pertinent to the chief complaint. Other
significant ongoing problems should be included in the HPI in a separate
section or paragraph. For instance, if a patient with poorly controlled
diabetes mellitus comes to the emergency department because of chest
pain, the HPI should first include information regarding the chest
pain followed by a detailed history of the diabetes mellitus. If
the diabetes mellitus is diet controlled or otherwise well controlled,
the history of the diabetes mellitus may be placed in the past medical
- Past Medical History (PMH): Current
medications, including OTC medications, vitamins, and herbal agents;
allergies (drug and other, as well as specific allergy manifestations);
operations; hospitalizations; blood transfusions, including when
and how many units and the type of blood product; trauma; and stable
current and past medical problems unrelated to the HPI. Adult patients: Ask about diabetes
mellitus; HTN; MI; stroke; PUD; asthma; emphysema; thyroid, liver,
and kidney disease; bleeding disorders; cancer; TB; hepatitis; and
STDs. Also ask about routine health maintenance. The questions for
this category depend on the age and sex of the patient but can include
last Pap smear and pelvic exam; breast exam; whether the patient
does breast self-examinations; date of last mammogram; diphtheria/tetanus
immunization; pneumococcal, influenza, and hepatitis B vaccines;
stool samples for occult blood; sigmoidoscopy or colonoscopy; cholesterol;
HDL cholesterol; functioning smoke alarms on each floor at home;
and use of seat belts. Pediatric patients: Include
prenatal and birth history, feedings, food intolerance, immunization
history, hot water heater temperature setting, and use of bicycle
- Family History: Age, status
(alive, dead) of blood relatives and medical problems of blood relatives
(ask about cancer, especially breast, colon, and prostate; TB, asthma;
MI; HTN; thyroid disease; kidney disease; PUD; DM; bleeding disorders;
glaucoma, macular degeneration; and depression and alcohol or substance
abuse). Write out or use a family tree (see Figure in example of
a complete H&P write-up).
- Psychosocial (Social) History: Stressors
(financial, significant relationships, work or school, health) and
support (family, friends, significant other, clergy); lifestyle
risk factors (alcohol, drugs, tobacco, and caffeine use; diet; exercise;
exposure to environmental agents; ...
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.