History and Physical template

For clinical documentation tips

  • Chief complaint
  • History of present illness
  • Pain assessment
  • Past medical history
  • Current medications
  • Allergies
  • Family history
  • Social history
  • Primary care physician
  • Psychosocial history
  • Review of systems
  • Physical Examination
    • General exam
    • Vitals
    • System exam
  • Pertinent labs and diagnostics
  • Admission problems with diagnosis
    • Remember to document acuity even when it is obvious include terms like congenital, chronic, acute, acute on chronic, acute exacerbation
    • detail process that required the admission or surgery.
    • list every disease or condition present at admission that is suspected, tested for, monitored, medicated and link with underlying disease.
    • document significance and interdependence of coexisting conditions. Especially think if malnutrition if it is present.
    • make sure the following are documented if present
      • pressure ulcer, where?
      • anemia with cause
      • leukocytosis, why?
      • pneumonia
      • right heart failure
      • pulmonary edema, cardio genie or non-cardiogenic
      • heart failure?
      • acute or chronic osteomyelitis
  • Treatment plan

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