Writing a History and Physical

By

  • Jeffrey Greenwald, MD, Assistant Professor of Medicine, Division of General Internal Medicine, Boston Medical Center, Boston, MA

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.
View full description

Audience

Medical Students, Nurse Practitioners, Physician Assistants

 

Book information

  • Published: May 2003
  • Imprint: HANLEY AND BELFUS MEDICAL PUBLISHERS
  • ISBN: 978-1-56053-602-4


Table of Contents

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