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Written History and Physical LSU Pediatric ClerkshipStudent Name Clinical Preceptor Patients DOB Hospital Date of H & P HistoryChief Complaint:History of Present Illness ***Any birth history, past
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Written history and physical is a detailed report on a patient's medical history, symptoms, and physical examination findings recorded by a healthcare provider.
Healthcare providers including doctors, nurses, and other medical professionals are required to file written history and physical for their patients.
To fill out written history and physical, healthcare providers must gather information from the patient, perform a physical examination, and document their findings in the designated form.
The purpose of written history and physical is to provide a comprehensive overview of a patient's health status, aid in diagnosis and treatment decisions, and establish a baseline for future medical assessments.
Written history and physical must include details about the patient's medical history, current symptoms, physical examination findings, diagnostic test results, and treatment plans.
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