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PEDIATRIC CLERKSHIP MANUAL SE CAMPUSFARGO1 Vegetable of Contents Curriculum and Objectives3IntroductionInpatient, Outpatient, Subs. Clinic, NNN, CTC4Pediatric Clerkship Requirements9Inpatient H&P

How to fill out history and physical examination

How to fill out history and physical examination

1. To fill out a history and physical examination, follow these steps:
2. Begin by gathering the patient's personal information, such as their name, date of birth, and contact details.
3. Obtain a detailed medical history, including any past illnesses, surgeries, or chronic conditions.
4. Record the patient's current medications, allergies, and immunization status.
5. Ask the patient about their family medical history, specifically any hereditary conditions.
6. Conduct a thorough physical examination, starting from head to toe, documenting any abnormalities or findings.
7. Measure vital signs, including blood pressure, heart rate, respiratory rate, and temperature.
8. Perform specialized examinations based on the patient's symptoms or concerns, such as neurological or cardiac examinations.
9. Document all findings accurately, using appropriate medical terminology.
10. Summarize the patient's overall health status and provide recommendations or follow-up instructions.
11. Review and sign the history and physical examination form, ensuring it is complete and legible.

Who needs history and physical examination?

1. History and physical examinations are generally needed by:
2. - Individuals seeking initial medical assessment or routine check-ups.
3. - Patients scheduled for surgeries or invasive procedures.
4. - Individuals with specific symptoms or complaints, requiring further diagnosis.
5. - Employees, students, or athletes undergoing pre-employment or pre-participation screenings.
6. - Individuals participating in certain clinical trials or research studies.

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What is history and physical examination?

History and physical examination is a medical assessment that involves gathering information about a patient's medical history, conducting a physical examination, and documenting findings.

Who is required to file history and physical examination?

Healthcare providers, such as doctors, nurse practitioners, and physician assistants, are typically responsible for conducting and documenting history and physical examinations.

How to fill out history and physical examination?

To fill out a history and physical examination, healthcare providers will typically ask the patient about their medical history, perform a physical exam, and record their findings in a medical record.

What is the purpose of history and physical examination?

The purpose of a history and physical examination is to gather information about a patient's health status, identify any potential health issues, and develop a treatment plan.

What information must be reported on history and physical examination?

Information that must be reported on a history and physical examination includes the patient's medical history, current symptoms, vital signs, physical exam findings, and any diagnostic test results.