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HISTORY AND PHYSICAL EXAMINATION INPATIENTS, AMBULATORY SURGERY PATIENTS, OBSERVATION PATIENTS PT. NAME: HOSPITAL# ADM. DATE HISTORY: Source: Chief Complaint: Patient Family Member Medical Record

How to fill out history and physical examination

How to fill out history and physical examination:

1. Start by gathering the patient's demographic information, including their name, age, gender, and contact information.
2. Begin the history portion by asking the patient about their chief complaint or the reason for their visit. Document their symptoms, duration, and any relevant past medical history.
3. Ask about the patient's medical history, including any previous surgeries, hospitalizations, chronic illnesses, or family history of diseases.
4. Inquire about the patient's medication history, including any current prescriptions, over-the-counter medications, and herbal supplements. Make note of any allergies or adverse reactions to medications.
5. Obtain a detailed social history by asking about the patient's occupation, living situation, tobacco or alcohol use, and any recreational drug use. It's important to also ask about their sexual history and any relevant immunizations.
6. Perform a thorough physical examination, starting from head to toe, documenting any abnormalities or findings. This should include vital signs, general appearance, neurologic assessment, cardiovascular assessment, respiratory assessment, and any focused examinations based on the patient's complaint.
7. Upon completing the history and physical examination, summarize and document the findings in a clear and concise manner. Include any relevant diagnoses, differential diagnoses, and a plan for further investigations or treatment.
8. It is important to communicate the findings with the patient, address any concerns, and involve them in the decision-making process regarding their healthcare.
9. Finally, sign and date the history and physical examination documentation to authenticate the information.

Who needs history and physical examination:

1. Individuals seeking routine or preventive medical care often undergo history and physical examinations. These examinations provide a baseline assessment of their overall health and aid in identifying any potential risk factors or underlying medical conditions.
2. Patients presenting with specific symptoms or complaints, such as pain, changes in bodily functions, or concerning signs, may require a history and physical examination to determine the cause and guide further diagnostic tests or treatment.
3. History and physical examinations are also crucial in pre-operative assessments to ensure patients are fit for surgery and to identify any conditions that may affect the surgical outcome.
4. Patients undergoing medical evaluations for insurance or disability claims may also require a history and physical examination to provide objective evidence of their medical conditions.

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