Get the free H+p* history and physical (structured) - OhioHealth

PATIENT NAME AGE CODE STATUS INFORMANT DATE OF EXAM ER ADMISSION Patient Other TIME OF EXAM DIRECT FLOOR ADMISSION PROP ADMISSION PRESENT MEDICATIONS AND DOSAGES CHIEF COMPLAINT See Medication Reconciliation

How to fill out hp history and physical

How to fill out an hp history and physical:

1. Start by gathering all necessary information about the patient, such as their full name, date of birth, and contact information.
2. Begin the history section by documenting the patient's chief complaint or reason for seeking medical evaluation. Include any relevant symptoms or concerns mentioned by the patient.
3. Proceed to obtain a detailed medical history from the patient. Ask about any past or current medical conditions, surgeries, allergies, medications, and family history of diseases. Document any significant events or treatments that may impact the patient's current health status.
4. Inquire about the patient's social history, including their occupation, marital status, living situation, and any harmful habits like smoking or excessive alcohol consumption. This information can provide insight into potential environmental factors affecting their health.
5. Assess the patient's psychosocial history by asking about their emotional well-being, stress levels, and any history of mental health disorders. Consider any past or ongoing treatments, therapy, or medications related to mental health.
6. Move on to documenting the patient's current habits and lifestyle choices, such as exercise routines, eating habits, and any drug or substance use. This information helps evaluate the patient's overall health and potential risk factors.
7. Perform a thorough review of systems by asking about each major body system, including cardiovascular, respiratory, gastrointestinal, neurological, and musculoskeletal. Document any pertinent positive or negative findings mentioned by the patient.
8. Proceed to the physical examination section. Include the patient's vital signs, such as blood pressure, heart rate, respiratory rate, and temperature measurements. Document any abnormalities or noteworthy findings during the examination of each body system.
9. Finally, summarize the findings and impressions in the assessment and plan section. Include any additional tests, referrals, or follow-ups recommended based on the history and physical examination.

Who needs an hp history and physical?

1. Patients undergoing pre-operative evaluations require an hp history and physical to assess their medical status and identify any potential risks before undergoing surgery.
2. Individuals enrolling in certain educational programs, employment positions, or participating in specific activities like sports may need an hp history and physical to ensure they are medically fit to engage in those activities.
3. Some healthcare facilities or organizations may require an hp history and physical for their employees to ensure they meet the necessary health requirements for their job and ensure the safety and well-being of patients or clients.

In summary, filling out an hp history and physical involves gathering comprehensive patient information, documenting the patient's medical, social, and psychosocial history, performing a physical examination, and summarizing the findings and recommendations. This process is necessary for pre-operative evaluations, participation in certain activities, or as a requirement for certain job positions.

For pdfFiller’s FAQs

What is hp history and physical?

Hp history and physical is a detailed document that outlines a patient's medical history and physical examination findings.

Who is required to file hp history and physical?

Healthcare providers such as doctors, nurses, and other medical professionals are required to file hp history and physical.

How to fill out hp history and physical?

Hp history and physical can be filled out by conducting a thorough medical history interview with the patient and performing a comprehensive physical examination.

What is the purpose of hp history and physical?

The purpose of hp history and physical is to gather important medical information about a patient and to document their current health status.

What information must be reported on hp history and physical?

Information such as past medical history, allergies, current medications, family history, and physical examination findings must be reported on hp history and physical.

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