Get the free HISTORY AND PHYSICAL EXAMINATION FORM ... - UW Health - uwhealth

HISTORY AND PHYSICAL EXAMINATION FORM Student Name: Clinical Site: Date in Clinical: Medical Record Number: GENERAL IMPRESSION (demographics): CHIEF COMPLAINT (CC) / Primary DX: HISTORY OF PRESENT

How to fill out history and physical examination

How to fill out history and physical examination?

1. Begin by gathering relevant information about the patient's medical history. This includes details about any past illnesses, surgeries, allergies, medications, and family history of diseases.
2. Document the patient's vital signs, which include measurements such as blood pressure, heart rate, and temperature. This provides a baseline for the patient's current health status.
3. Conduct a thorough physical examination by systematically assessing the patient's various body systems. This may involve examining the patient's head and neck, chest and abdomen, limbs, and other relevant areas.
4. Utilize appropriate medical terminology to accurately describe any findings or abnormalities during the physical examination.
5. Ask the patient about their current symptoms or complaints, taking note of any changes or progression. This helps in diagnosing any underlying health conditions.
6. Record the patient's social and lifestyle factors that may impact their health, such as smoking, alcohol consumption, exercise habits, and occupation.
7. Ensure all gathered information is organized and properly documented in the patient's medical record. This includes using appropriate headings and subheadings for different sections of the history and physical examination.
8. Review the completed history and physical examination, ensuring all necessary information has been included and accurately recorded.

Who needs history and physical examination?

1. Individuals seeking medical care: History and physical examinations are essential for patients who require medical attention, whether it is for routine check-ups, acute illnesses, chronic conditions, or preventive care.
2. Medical professionals: History and physical examinations are necessary for healthcare providers, including doctors, nurses, and allied health professionals, who need to gather comprehensive information about their patients to make accurate diagnoses and develop appropriate treatment plans.
3. Institutions and organizations: History and physical examinations play a crucial role in healthcare institutions, including hospitals, clinics, and research facilities, as they help maintain accurate medical records, ensure patient safety, and facilitate continuity of care among different healthcare providers.

For pdfFiller’s FAQs

What is history and physical examination?

History and physical examination are two important components of a medical assessment. The history involves gathering information about a patient's medical background, symptoms, and any previous treatments, while the physical examination involves a thorough evaluation of the patient's body to assess their overall health and detect any abnormalities.

Who is required to file history and physical examination?

Healthcare professionals, such as doctors, nurses, and physician assistants, are generally responsible for conducting and documenting history and physical examinations for their patients.

How to fill out history and physical examination?

Filling out a history and physical examination involves asking the patient relevant medical history questions, documenting their answers, conducting a physical examination, and recording the findings. It is crucial to be thorough and accurate when filling out these forms to ensure comprehensive patient assessment.

What is the purpose of history and physical examination?

The purpose of history and physical examination is to gather comprehensive information about a patient's health, identify any existing medical conditions or potential risk factors, and aid in diagnosing and treating their health issues. It helps healthcare professionals make informed decisions regarding patient care.

What information must be reported on history and physical examination?

The history section should include the patient's personal and family medical history, past surgeries or treatments, allergies, current medications, and any symptoms they are experiencing. The physical examination section should document the findings of the examination, including vital signs, general appearance, and specific organ system evaluations.

How do I edit history and physical examination in Chrome?

history and physical examination can be edited, filled out, and signed with the pdfFiller Google Chrome Extension. You can open the editor right from a Google search page with just one click. Fillable documents can be done on any web-connected device without leaving Chrome.

Can I create an electronic signature for the history and physical examination in Chrome?

Yes. By adding the solution to your Chrome browser, you can use pdfFiller to eSign documents and enjoy all of the features of the PDF editor in one place. Use the extension to create a legally-binding eSignature by drawing it, typing it, or uploading a picture of your handwritten signature. Whatever you choose, you will be able to eSign your history and physical examination in seconds.

Can I edit history and physical examination on an Android device?

The pdfFiller app for Android allows you to edit PDF files like history and physical examination. Mobile document editing, signing, and sending. Install the app to ease document management anywhere.