A History and Physical (H&P) is the foundational document in medical care, serving as the standardized, comprehensive record for a patient’s initial evaluation. This detailed report captures all the information a healthcare provider gathers at the beginning of an encounter, whether for a routine check-up, an acute illness, or a hospital admission. The H&P is a narrative that guides the entire diagnostic process, establishes a baseline for the patient’s health, and ensures seamless communication among all members of the healthcare team. It organizes the patient’s story and the provider’s findings into a format that supports the logical development of a diagnosis and treatment plan.
The Subjective Component: Gathering the Patient’s History
The first section of the H&P, the “History” or subjective component, focuses on information reported directly by the patient or a reliable representative regarding their health. This begins with the Chief Complaint (CC), a brief statement, often in the patient’s own words, describing the primary reason for the visit. For example, a patient might report “worst headache of my life” or “chest pain for three hours.”
The History of Present Illness (HPI) provides a chronological, detailed narrative of the current symptoms. The clinician uses a structured approach to detail the symptom’s onset, location, quality (e.g., sharp, dull), quantity (e.g., severity on a 1-10 scale), duration, setting, and any factors that aggravate or alleviate the problem. This section builds a complete picture of the patient’s current struggle.
The medical history expands to include Past Medical History (PMH), listing all previously diagnosed conditions, prior surgeries, or hospitalizations. A thorough Medication History is also captured, including prescription drugs, over-the-counter medications, and supplements, alongside any known allergies and the specific reactions they cause.
The provider documents the Family History, looking for hereditary patterns of disease in first-degree relatives, which can inform the patient’s risk. The Social History details lifestyle factors such as occupation, living situation, tobacco, alcohol, and illicit drug use, as these profoundly influence health and recovery. Finally, the Review of Systems (ROS) is a comprehensive, head-to-toe inventory of symptoms, ensuring no complaint is overlooked.
The Objective Component: Performing the Physical Examination
The second major section, the “Physical Examination” or objective component, documents verifiable data collected by the clinician through direct observation, measurement, and physical assessment techniques. This process starts with the Vital Signs, which are the fundamental physiological measurements, including temperature, heart rate, respiratory rate, and blood pressure. These measurements provide immediate indicators of the patient’s current state.
The examination proceeds systematically, often starting with a General Appearance survey, noting overall physical characteristics, mental status, and level of distress. The clinician then moves through a head-to-toe assessment of the body’s organ systems, using techniques such as inspection, palpation (touch), percussion (tapping), and auscultation (listening). For instance, a respiratory assessment involves auscultating the lungs for abnormal sounds like wheezes or crackles.
The physical exam includes a detailed check of the Head, Eyes, Ears, Nose, and Throat (HEENT). The cardiovascular assessment focuses on listening to heart sounds for murmurs or rhythm disturbances and checking peripheral pulses. An abdominal exam involves careful palpation to check for organ enlargement or tenderness, providing direct evidence related to the patient’s complaints.
The musculoskeletal and neurological systems are also systematically evaluated, checking reflexes, strength, sensation, and range of motion. All findings, whether normal or abnormal, are documented as factual, measurable observations. This objective data serves to either support or contradict the subjective information provided in the patient’s history.
Synthesis and Application: Creating the Assessment and Plan
The final sections of the H&P, the Assessment and the Plan, represent the application of clinical reasoning, synthesizing the subjective and objective data collected. The Assessment is the medical conclusion, where the provider lists the patient’s problems and establishes a diagnosis or a differential diagnosis—a list of the most probable conditions that could explain the findings. This section explicitly links the patient’s reported symptoms and the physical exam findings to the potential medical conditions.
The Assessment should not simply summarize the history or physical exam, but rather articulate the clinician’s thought process and justification for the proposed diagnoses, often prioritizing the most urgent or likely problems. The physician may use clinical criteria to support their diagnostic reasoning in this section. All the gathered information is filtered through medical knowledge to arrive at a professional interpretation of the patient’s condition.
Following the Assessment is the Plan, which is the proposed course of action for each identified problem. This outlines the next steps in patient management, which may include ordering specific laboratory tests, imaging studies, or other diagnostic procedures to confirm or exclude diagnoses. It also details the therapeutic interventions, such as starting or adjusting medications, beginning a specific treatment, and arranging consultations with specialists.
The Plan also includes patient education and discharge planning, ensuring the patient understands their condition and the necessary follow-up care. The H&P, completed with a structured Assessment and Plan, transforms raw data into a coherent strategy for patient care, serving as the documented blueprint for all subsequent treatment decisions.