History and Physical Exam: Introduction
In Medicine We Have Lines of Medical Communication:
- The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending. It always includes the Assessment and Plan, or the summation of our clinical reasoning. We always complete a formal H&P on a new patient in the office and for admission to the hospital; it is required. Although it is called "History and Physical," it includes an assessment and plan. The assessment may be a differential diagnosis, a list of symptoms, or a problem list. In annual preventative health assessments, we will have goals to accomplish: i.e., weight loss, BP < 130/80, etc.
- SOAP Note: The SOAP Note is an update on an existing problem as in a post op visit or follow up of a problem. This format is used in inpatient and outpatient settings, and is organized in the subjective, objective, assessment, and plan format that you have been using in year 1 and 2.
- Structured Patient Handoff: An example is SBAR used in handing off a patient to the next call team or in emergencies where there is no time for a full H&P presentation. SBAR is an acronym: S-Situation, B-Background, A-Assessment, R-Recommendations. Listen for this type of communication when nurses report to the physician on a patient's status.
Suzanne Bush, MD 2015
Books
Publication Date: 2009
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Additional Readings
SOAP Notes and H&P
Template used for the Pediatrics clerkship at Tulane School of Medicine. (https://tmedweb.tulane.edu/portal/student-guide/clerkships/item/pediatrics?category_id=10, downloaded August 2015)
Template used for the Pediatrics clerkship at Utah School of Medicine. (http://www.ped.med.utah.edu/cai/howto/, downloaded August 2015)
Commercial website example of history and physical for an initial obstetrical examination.
Templates and tips on H&P documentation from the University of Michigan’s Michigan Medicine.
Outline of gynecologic history from the Global Library of Women's Medicine.
The SOAP-V model prompts the consideration of (1) the evidence that supports a test or treatment, (2) the patient's preferences and values, and (3) the financial cost of a test or treatment compared to alternatives.
SBAR or Hand-Off Note
Detailed description of how a hospital uses SBAR communication for situations when a patient is transferred from one caregiver to another. From PinnacleHealth.
The Joint Commission formally recommends SBAR as a means to meet the Patient Safety Goal of standardized communication, and includes a link to the IHI's SBAR Toolkit.
Discharge Summary
From the "For Dummies" people, the content and format of a generic discharge summary are given in detail.
