The History and Physical (H&P) is a foundational document in healthcare that represents the initial, comprehensive assessment of a patient. It is the structured process a healthcare provider uses to gather information about a patient’s health status upon entering a care setting, such as a hospital or new clinical practice. The H&P serves as the official starting point of the patient’s medical record, detailing why they are seeking attention and their current health profile. This standardized documentation ensures that all subsequent care is built upon a complete understanding of the patient’s background and current symptoms. The H&P is required for hospital admission and is often completed within 24 hours of arrival or prior to any major procedure requiring anesthesia.
The Subjective Details: What the “History” Includes
The “History” portion of the H&P is the subjective component, gathered through a detailed interview with the patient or their family, capturing their experience of illness. This section begins with the Chief Complaint (CC), the single, concise reason the patient is seeking medical attention, often recorded in their own words. This complaint then expands into the History of Present Illness (HPI), a detailed, chronological narrative describing the symptom’s onset, location, duration, character, and factors that make it better or worse.
The provider collects the Past Medical History (PMH), which inventories all previous health conditions, hospitalizations, surgeries, and immunizations. The Social History (SH) documents lifestyle factors that influence health, such as occupation, diet, exercise habits, and the use of tobacco, alcohol, or other substances. A patient’s living situation and social support are also documented, as these factors impact recovery and treatment adherence.
A thorough Family History (FH) notes the presence of certain diseases, like cancer or heart disease, in first-degree relatives, which helps identify potential genetic or familial risk factors. Finally, the Review of Systems (ROS) is a comprehensive, head-to-toe inventory of symptoms across all major body systems. The ROS systematically asks about the skin, respiratory tract, cardiovascular system, and others to ensure no minor complaint is missed.
The Objective Findings: What the “Physical” Exam Reveals
The “Physical” component is the hands-on, objective part of the H&P, where the provider collects measurable data through observation and physical manipulation. The examination starts with the collection of Vital Signs, which are physiological measurements like temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. These measurements establish a baseline for the body’s functions. The provider then documents the patient’s General Appearance, noting their overall state, including alertness, body habitus, and signs of distress or pain.
The examination proceeds systematically, often moving from head to toe to ensure a complete evaluation of all organ systems. The provider uses four classic techniques: inspection (looking), palpation (feeling), percussion (tapping), and auscultation (listening). For example, a pulmonary assessment involves auscultating the lungs for abnormal breath sounds, while an abdominal exam uses palpation to check for organ enlargement or tenderness.
The neurological exam assesses mental status, motor function, sensation, and reflexes, providing objective data on the central nervous system’s integrity. Findings for each system, such as a regular heart rhythm or clear lung sounds, are recorded as factual observations. This systematic collection of objective data provides verifiable information that supports or contradicts the subjective narrative gathered in the history section.
The Essential Role of the H&P in Diagnosis and Treatment
The H&P is the framework that allows a provider to bridge reported symptoms with observable findings to develop a medical plan. By integrating the subjective history with the objective physical exam, the provider formulates an Assessment, which includes a list of possible diagnoses, known as the differential diagnoses. The details gathered guide the diagnostic process effectively.
The completed H&P directly informs the Plan, which outlines the next steps in the patient’s care. This includes necessary diagnostic tests, such as blood work or imaging, and the initial treatment strategy. Since most diagnoses rely on the history and physical, this document helps focus the investigation and prevents unnecessary testing.
The H&P establishes a baseline for the patient’s health status against which future changes and responses to treatment can be measured. It also functions as a central communicative record, ensuring every member of the care team has immediate access to the necessary information for safe and coordinated care. The accuracy and completeness of the H&P are mandatory, as the document serves as both a clinical tool and a legal record.