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This document outlines the policy for completing the Admission History and Physical at Harbor-UCLA Medical Center. It details the required components of the medical record, including the history of present illness, physical examination findings, and necessary documentation within specific timeframes. It also describes procedures for updating records and conditions under which prior history may be used.

How to fill out admission history and physical

How to fill out admission history and physical

1. Start with the patient's identification information: name, date of birth, and medical record number.
2. Document the patient's chief complaint and reason for admission.
3. Collect the patient's medical history, including previous illnesses, surgeries, and current medications.
4. Record the patient's family medical history, noting any hereditary conditions.
5. Complete the social history, including lifestyle factors such as smoking, alcohol use, and occupation.
6. Conduct a review of systems, assessing each body system for additional symptoms or issues.
7. Perform a comprehensive physical examination, noting vital signs and any abnormal findings.
8. Summarize the impression and any preliminary diagnosis based on the collected information.
9. Include a plan for further evaluation, treatment, or referrals as appropriate.

Who needs admission history and physical?

1. Patients being admitted to a hospital.
2. Healthcare providers who need to establish a baseline for patient care.
3. Insurance companies for documentation and billing purposes.
4. Medical staff involved in the patient's healthcare team.

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What is admission history and physical?

Admission history and physical (H&P) is a comprehensive assessment of a patient's medical history and physical examination conducted at the time of hospital admission. It provides essential information for diagnosing and planning treatment.

Who is required to file admission history and physical?

Typically, a physician or other qualified healthcare professional is required to file the admission history and physical as part of the patient's medical record upon admission to a healthcare facility.

How to fill out admission history and physical?

To fill out an admission history and physical, collect detailed information on the patient's medical history, including past illnesses, surgeries, allergies, and medications, followed by a thorough physical examination, documenting all findings accurately.

What is the purpose of admission history and physical?

The purpose of the admission history and physical is to establish a baseline for the patient's health, guide treatment decisions, ensure accurate diagnoses, and facilitate communication among healthcare providers.

What information must be reported on admission history and physical?

The admission history and physical must report demographic information, medical history, medication history, allergies, family history, social history, and findings from the physical examination.