A History and Physical Reports(H&P)
The primary purpose of the H&P is to assist the physician in making a diagnosis on which he or she will base the patient care and treatment. The H&P is prepared on all hospitalized patients and outpatients in need of extensive evaluation. In the previous part of this chapter, you learned how an H&P is set up in its condensed form: the chart note. The SOAP format is a miniature H&P, though several formats are used for typing an H&P. There is no est?style or method, but each hospital, clinic, or medical office should adopt a standard outline.
As its title indicates, the H&P is broken down into two sections, the history and the physical. The history, or historical component of the two reports, is a summary of the chronological record of situations, events and other associated topics that may have contributed to the patient's admission into the hospital. The history portion of the report is sometimes called the Subjective, because it related to the patient's own sense or awareness of his or her condition and the circumstances surrounding it, factors which may or may not be able to be demonstrated. The main sections of the history section are entitled History of the Present Illness (HPI) and the Review of Systems (ROS), or Systems Review.
The HPI is the patient's oral history given to the doctor concerning the onset and duration of the illness, as well as any precipitating factors the patient may associate with the condition. The HPI can also contain subsections concerning the patient's past medical history, which details any previous major illness or related conditions, any chronic illnesses, any previous hospitalizations or surgeries, any prior treatment for the current condition, and the patient's current immunization record, if associated with the illness. Other HPI subsections can include family, educational and social (such as smoking and alcohol consumption) histories, if they have contributed to the illness; and any medications the patient may be taking.
The review of systems is a historical review of the patient's complaints specific to each body system. The physician asks the patient about each body system, and the patient responds as to whether or not he or she has had problems associated with that system in the past. Again, being part of the history, the ROS is subjective, with the patient providing an oral account of what he or she senses as disturbances or abnormalities with each part of the body. In the ROS, the patient tells the physician about his or her symptoms, that is, the sensory perception of the illness-the characteristics of the illness perceived by the patient through sight, sound, smell, taste or touch.
We will now examine some formats for H&P set-up: Figure II-1, Figure II-2 and Figure II-3. The actual wording of the outline itself may vary, too. Keeping the facts in the proper sequence, spacing them properly, and typing them accurately.
Some common abbreviations used in HP are below:
HEENT: head, ears, eyes, nose, and throat
CR: cardiovascular and respiratory system
GI: gastrointestinal system
OB-BYN: obstetrics and gynecological examination
GU: genitonurinary system
NM: nerve and muscular system
Figure II-1 Example of a history done on full block format
Figure II-2 Example of a history done in modified block format
Figure II-3 Example of a history done in run-on format
The end of the ROS is the crossroad of the H&P. Whereas the history focuses on the patientís subjective account of his or her current condition, the Physical, or Physical Examination (PE or PX), focuses on the characteristics of the illness that are objective, or capable of being demonstrated to the physician or others. These objective findings, or characteristics, of the disease, are often called signs. The physical examination is composed of a visual (what is seen) evaluation, and an auditory or aural(what is heard) evaluation, and olfactory(what is sense by the nose) evaluation, and a tactile( what is felt) evaluation, performed by the physician or health care provider. The physical exam is a series of comprehensive evaluations of the patientís body systems and organs, for example, the patientís height and weight, heart sounds, skin condition, nodules felt, reflex strength, body scents, and so on.
Four basic procedures are included in the complete PX:
1.Inspection: looking at the body.
2.Palpation: feeling various parts and organs.
3.Percussion: listening to the sounds produced when a particular region is tapped (percussed).
4.Auscultation: listening to body sounds.
The style and format for the PX are identical to those for the history. Be consistent and follow the same style you use for the history when typing the PX. The PX is typed on a separate sheet of paper with full headings.
The H&P also usually contains two additional sections, one that formally assesses the patient's condition, also sometimes called the Impression, Assessment, or Admitting Diagnosis or Diagnoses, and another that provides a plan of action for the hospitalization, usually called the plan or treatment plan.
Now let's take a look at some examples of complete H&P.
Figure II-4Example of a history done on full block format.
Figure II-5Example of a history done in modified block format.
The history includes the chief complaint (CC), the history of present illness (HPI), the review of system (ROS), and past history, family, and /or social history (PFSH).
The CC describes the symptom, problem, or condition that is the reason for the encounter, and this must be clearly described in the record.
The HPI is the chronological description of the development of the patientís present illness from the first sign and/or symptom or from the previous encounter to the present.
A problem-pertinent ROS inquires about the system directly related to the problems identified in the HPI. The patient's positive responses and pertinent negative related to the problem are documented. Signs or symptoms the patient might be experiencing or has experienced are identified, including constitutional symptoms (fever, weight loss, fatigue); integumentary (skin and /or breast); eyes, ears, nose, and throat; mouth; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; neurologic; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic. The ROS and PFSH may be recorded by an ancillary staff member or on a form completed by the patient. When directly related to the problem identified in the HPI, the PFSH is a review of the patient's past illnesses, operations, injuries, and treatments; a review of medical events in patient's family, including diseases that may be hereditary; and review of past and current activities in which the patient was or is engaged. (The time spent with the patient in history taking, care, examination, counseling, and coordination of services should also be documented.)