Chapter 6: The History and Physical Examination

INTRODUCTION

HISTORY AND PHYSICAL EXAMINATION, ADULT

First, some general comments about the initial history and physical (H&P) in particular, and medical records in general. The H&P write-up provides others on your team, and in the future, other healthcare providers caring for your patient, a record of the current hospitalization. Your H&P usually becomes part of the medical record and after review and sign-off by a senior physician, it becomes part of this living and breathing document. After your H&P is added to the chart, along with other H&Ps from the attending, resident, and intern, progress notes are added each day, as well as notes from consultants and other healthcare providers such as nurses, dieticians, and physical therapists. Whether an electronic medical record or an “old” paper-based record that is often scanned into the electronic health record (EHR), the patient chart is a legal document and needs to be treated as such. Your H&P, along with any other documentation added to the chart, should be legible, and the content should be clear and concise. Some outpatient practices may have their own format to document basic patient information.

Some important comments: The medical record is never a place to verbally “spar” with other physicians or services because of differences of opinion in the care of a patient. And just as important, the language used in our patient notes may introduce biases that may affect the care provided by future healthcare workers, and ultimately can adversely affect the health of the patient. Avoid the use of quotations around potentially sensitive subjects, such as alcohol use and behavior that could be interpreted in a negative light, such as “verbally abusive to the on-call doctor.”¹

The details, style, and length of a written history and physical exam will likely vary with the patient’s particular problem(s) and are typically based on the service to which the patient is admitted. Here we describe the general approach to the history and physical exam in an adult admitted to a general medical service. A sample general adult write-up can be found on Example of a History and Physical Examination, Adult . This chapter also highlights some specialty-specific key elements (obstetrics, ophthalmology, others) that may be helpful based on the ...