History & Physical Template
The H&P is the most comprehensive medical document. Use it for new patients, admissions, and consultations to capture a complete clinical picture.
Generate H&P Notes with AIWhat is a History and Physical?
A History and Physical (H&P) is the most comprehensive type of medical documentation. It provides a complete picture of a patient's health status, including their medical history, current symptoms, and physical examination findings.
H&P notes are typically required for new patient encounters, hospital admissions, and specialist consultations. They serve as the foundation for clinical decision-making and treatment planning.
H&P Note Sections
Chief Complaint (CC)
The primary reason for the visit in the patient's own words
History of Present Illness (HPI)
Detailed narrative of the current problem including onset, location, duration, character, aggravating/relieving factors, and associated symptoms
Past Medical History (PMH)
Previous illnesses, hospitalizations, surgeries, and chronic conditions
Medications
Current medications including dose, frequency, and route
Allergies
Drug allergies and adverse reactions with documented reactions
Family History (FH)
Medical conditions in first-degree relatives, particularly hereditary diseases
Social History (SH)
Occupation, tobacco/alcohol/drug use, living situation, sexual history if relevant
Review of Systems (ROS)
Systematic review of all body systems for additional symptoms
Physical Examination
Complete head-to-toe examination findings organized by system
Assessment
Diagnosis or differential diagnosis with clinical reasoning
Plan
Diagnostic workup, treatment, medications, follow-up, and patient education
When to Use an H&P
New Patient Visits
Comprehensive documentation for patients new to your practice
Hospital Admissions
Admission H&P required for inpatient care
Specialist Consultations
Detailed workup for specialty referrals
Pre-operative Evaluations
Comprehensive assessment before surgical procedures
H&P Notes in Seconds, Not Hours
Comprehensive H&P notes can take 20-30 minutes to write manually. PatientNotes AI generates them in under 60 seconds from your patient conversation.
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