Get the free HISTORY AND PHYSICAL EXAM OPERATIVE NOTES

UNIVERSITY OF MICHIGAN HOSPITAL & HEALTH CENTERS Manual Vacuum Aspiration Procedure Record Today's Date Referring provider Age: G: P: EGA weeks by: LMP US Preprocedure Vital Signs: B/P Pulse Temp

How to fill out history and physical exam

How to fill out history and physical exam:

1. Gather necessary information: Start by collecting the patient's personal and medical history, including any pre-existing conditions, allergies, current medications, lifestyle habits, and family medical history. This information will help provide a comprehensive understanding of the patient's health.
2. Begin with the subjective history: Sit down with the patient and ask open-ended questions to gather information about their chief complaint, symptoms, their onset, duration, severity, and any treatments they have tried. Additionally, inquire about any relevant personal or psychosocial factors that may impact their health.
3. Conduct a comprehensive review of systems: Go through each organ system and cover the relevant symptoms, asking specific questions pertaining to each system. This will help identify any overlooked issues and provide a holistic view of the patient's health.
4. Perform a physical examination: Start by checking the patient's vital signs, including blood pressure, heart rate, respiratory rate, and temperature. Then proceed to conduct a systematic examination of each body system, including inspection, palpation, percussion, and auscultation where applicable. Pay attention to any abnormal findings and document them appropriately.
5. Review and document: After gathering the history and performing the physical exam, review all the information obtained. Document the findings in a clear and concise manner, using appropriate medical terminology and objective descriptions. Ensure accuracy and completeness of the information provided.

Who needs history and physical exam:

1. New patients: It is crucial to perform a history and physical exam on new patients as it helps establish a baseline for their health. This information provides important insights into their medical history, symptoms, and overall health status.
2. Pre-operative patients: Prior to any surgical procedure, a thorough history and physical exam are performed to evaluate the patient's fitness for the surgery. This assessment helps identify any potential risks or complications that may arise during the operation.
3. Routine check-ups: Regular history and physical exams are recommended for individuals to monitor their general health, identify any potential issues, and create a longitudinal record of their well-being. These exams may be conducted annually or as per the individual's age, gender, and medical history.
4. Patients with specific complaints or symptoms: If a patient presents with specific complaints or symptoms, a history and physical exam are essential in determining the cause and formulating an appropriate treatment plan. It aids in narrowing down the differential diagnosis and guiding further investigations.
5. Individuals with chronic conditions: For patients with chronic conditions, regular history and physical exams are vital to monitor disease progression, assess treatment effectiveness, and identify any new complications or comorbidities that may have arisen.

In conclusion, filling out a history and physical exam entails gathering detailed patient information, conducting a thorough subjective and objective assessment, and documenting the findings accurately. It is essential for new patients, pre-operative patients, routine check-ups, patients with specific complaints or symptoms, and individuals with chronic conditions.

For pdfFiller’s FAQs

What is history and physical exam?

History and physical exam is a medical assessment conducted by healthcare professionals to gather information about a patient's medical history, current health status, and physical condition.

Who is required to file history and physical exam?

History and physical exam must be filed by the patient's healthcare provider or physician.

How to fill out history and physical exam?

History and physical exam can be filled out by answering the questions about the patient's medical history, current health issues, past surgeries, medications, allergies, and performing a physical examination.

What is the purpose of history and physical exam?

The purpose of history and physical exam is to assess the patient's overall health, detect any underlying medical conditions, plan appropriate treatment, and monitor the patient's progress.

What information must be reported on history and physical exam?

Information reported on history and physical exam includes the patient's medical history, current health concerns, medications, allergies, family history of diseases, and findings from physical examination.

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