History & Physical

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Patient Information:

  • Name: [Patient's Name]
  • Age: [Patient's Age]
  • Gender: [Patient's Gender]
  • Date of Admission: [Date]

Chief Complaint:

  • [Brief description of the patient's main reason for seeking medical attention]

History of Present Illness:

  • [Detailed description of the current illness or condition, including onset, duration, progression, exacerbating or alleviating factors, associated symptoms, and any previous treatments]

Past Medical History:

  • [Summary of the patient's past medical conditions, surgeries, hospitalizations, allergies, and chronic medications]

Medications:

  • [List of current medications, including prescription, over-the-counter, and supplements]

Allergies:

  • [List of known allergies and reactions]

Family History:

  • [Summary of significant medical conditions or diseases in the patient's family]

Social History:

  • [Description of the patient's lifestyle, including tobacco, alcohol, and substance use, occupation, living situation, and social support]

Review of Systems:

  • [Systematic review of symptoms, including constitutional symptoms, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, dermatological, and psychiatric symptoms]

Physical Examination:

  • [Detailed physical examination findings, including vital signs, general appearance, head and neck, chest, heart, abdomen, extremities, neurological assessment, and any pertinent positive or negative findings]

Assessment:

  • [Summary of the patient's current condition, including differential diagnoses and provisional diagnosis]

Plan:

  1. Diagnostic Tests:
    • [List of diagnostic tests to be ordered or performed, including laboratory tests, imaging studies, and procedures]
  2. Medications:
    • [Prescription medications, dosage, frequency, and instructions]
  3. Therapeutic Interventions:
    • [Any treatments or interventions planned, including procedures or surgeries]
  4. Consultations:
    • [Referrals to other specialties or healthcare providers]
  5. Follow-Up:
    • [Instructions for follow-up appointments, monitoring, and patient education]

Patient Education:

  • [Key points discussed with the patient regarding their condition, treatment plan, and self-management strategies]

Informed Consent:

  • [Confirmation of informed consent obtained for any procedures or treatments planned]

Disposition:

  • [Plan for discharge, admission, or transfer]

Provider Signature:

  • [Signature]
  • [Name]
  • [Credentials]
  • [Date and Time]