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HISTORY & PHYSICAL EXAM FORMATASSESSMENT / PLANNED OF DICTATING MD, PA, OR NP/ SUPERVISING MD (REQUIRED) PATIENT NAME MEDICAL RECORD NUMBER ADMIT DATE PRIMARY CARE MD / ADDRESS / PHONE# CHIEF COMPLAINT

How to fill out history amp physical exam

How to fill out history and physical exam:

1. Begin by gathering the necessary information from the patient. This includes their personal details, medical history, and any current complaints or symptoms they may be experiencing.
2. Conduct a thorough physical examination of the patient. This involves assessing their vital signs, examining different body systems, and performing any relevant tests or procedures.
3. Record all findings accurately and in detail. Use proper medical terminology and document any abnormalities or noteworthy observations.
4. Include the patient's medical history, which should cover past illnesses, surgeries, allergies, medications, and immunization history. This information is crucial for evaluating the patient's overall health and potential risk factors.
5. Document the patient's current medications, including dosage and frequency. This is important to ensure any potential drug interactions or contraindications are well understood.
6. Include a detailed review of systems that covers areas such as cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurological systems. This helps to evaluate the patient's overall health and detect any potential underlying issues.
7. Pay attention to the patient's psychosocial history, including their lifestyle habits, occupation, and social support system. This information provides valuable insights into the patient's overall well-being.
8. Don't forget to obtain and document the patient's informed consent for the examination and any relevant procedures.
9. After completing the history and physical exam, review the findings and draw conclusions. This may involve formulating a differential diagnosis and creating a plan for further investigations or treatment.
10. Communicate the findings to the patient and any relevant healthcare professionals involved in their care. Ensure that all necessary documentation is complete and accurate.

Who needs history and physical exam?

1. Patients seeking comprehensive healthcare: A history and physical exam is essential for individuals looking for a comprehensive evaluation of their overall health. It helps identify potential risk factors, detect underlying health conditions, and outline appropriate medical interventions.
2. Preoperative patients: Prior to undergoing surgery, patients must undergo a history and physical exam to assess their overall health status. This evaluation is crucial in identifying any potential surgical risks or complications and in determining the most suitable anesthesia approach.
3. Occupational health assessments: Certain professions, particularly those involving physical labor or exposure to specific hazards, require regular history and physical exams to ensure the worker's fitness for duty. These evaluations help in preventing workplace injuries and maintaining a safe work environment.
4. Sports and wellness screenings: Athletes, particularly those engaged in competitive sports, often undergo regular history and physical exams to ensure their fitness and ability to participate. These exams help identify any underlying medical issues, prevent sports-related injuries, and guide appropriate training and treatment plans.
5. Routine check-ups: Many healthcare providers recommend periodic history and physical exams for individuals, regardless of age or medical history. These routine assessments facilitate early detection and intervention for potential health concerns, promoting overall well-being.

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