Central to providing excellent patient care is excellent communication, for which a well-written History and Physical is crucial. This book is a step-by-step guide to help medical students, nurse practitioners, physician
assistants, etc. write a comprehensive, clear, and useful History and Physical. Writing an effective History and Physical is as much an art as science, and this handy guide provides a roadmap for organizing facts in a logical and well-constructed fashion. The text also presents an abridged version for quick reference and a valuable section on how to write daily progress notes.
1. Source 2. Chief Complaint (CC) 3. History of the Present Illness (HPI) 4. Past Medical History (PMH) 5. Medications (Meds) 6. Allergies (All) 7. Family History (FHx) 8. Social History (SHx) 9. Review of Systems (ROS) 10. Physical Exam (PE) 11. Laboratories/Data 12. Assessment/Impression/Summary 13. The Plan 14. Problem List 15. Organ System Approach 16. Writing a History and Physical: The Abridged Guide 17. Writing a Daily Progress