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History and Physical Note Template

Chief Complaint or Reason for Consult: Why the patient is seeking medical care or the reason

you have been consulted.

History of Present Illness (HPI): History of present illness is the “Who, What, When, Where,

Why, How, How Long” section used to document the patient’s story related to the chief

complaint or consult.

Past Medical History: A list of all medical diagnoses (include pertinent information such as a

new diagnosis). Identify the length of the diagnosis with either year or longevity.

Past Surgical History: A list of all surgeries. Be sure to include the date of the surgery.

Family History: First-degree pedigree medical diagnoses—be sure to include age and cause of

death of family members.

Social History: A synopsis of work, tobacco, alcohol, drug use, marital status, residence, travel,

functional status, and surrogate/advanced directives.

Allergies: A list of medication or food allergies and the type of reaction the patient experiences

when exposed to the foods or medications.

Home Medications: List all home medications and the dosage in milligrams and frequency.

Document adherence, including prn/over-the-counter and how often the patient takes prn

medications.

Hospital Medications: List the name, milligrams, frequency, and route if you are seeing the

patient after being admitted.

Review of Systems: Review of symptoms (told by the patient or family) but organized by

system. Must have 12 systems with at least 2 pertinent +/-

• CONSTITUTIONAL: These are the patient’s answers about general constitutional signs or symptoms.
Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out

functions of daily living.

• EYES: These are the patient’s answers about signs or symptoms that may include the use of glasses, eye
discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light

sensitivity, swelling around the eyes or lids, and visual disturbances.

• EARS, NOSE, and THROAT: These are the patient’s answers about signs or symptoms, including
sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and

abnormalities. It could include nosebleed, postnasal drip, frequent sneezing, frequent nasal drainage,

impaired ability to smell, sinus pain, difficulty breathing, or history of sinus infection and treatment. For

the throat and mouth: sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums,

history of hoarseness, change in voice quality, difficulty in swallo

History and Physical Note

12 points

Criteria Description

History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)

5. Target

12 points

The history and physical note is thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The history and physical note is provided with appropriate details and support.

3. Approaching

9.6 points

The history and physical note is present, but only minimal detail or support is provided.

2. Insufficient

6 points

The history and physical note is incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The history and physical note is not included.

Assessment and Clinical Impressions

12 points

Criteria Description

Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)

5. Target

12 points

The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The assessment and clinical impressions are provided with appropriate details and support.

3. Approaching

9.6 points

The assessment and clinical impressions are present, but only minimal detail or support is provided.

2. Insufficient

6 points

The assessment and clinical impressions are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The assessment and clinical impressions are not included.

Plan Component Management and Criteria

12 points

Criteria Description

Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)

5. Target

12 points

The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The plan component management and plan criteria incorporation are provided with appropriate details and support.

3. Approaching

9.6 points

The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.

2. Insufficient

6 points

The plan component management and plan criteria incorporation are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The plan component management and plan crit

Admission History and Physical

ANP 652: Robin McLinn

Patient Name: A.S. DOB: 03/15/1992

Provider: ACNP Student Robin McLinn RM#: ED #14

ADM: 07/14/2020 Patient Type: Tele Inpatient

CHIEF COMPLAINT: Chief Complaint: “I have had a fever for 3 days with diarrhea starting today, I feel really tired and can’t catch my breath. I had a COVID 19 test come back positive from an outside lab”

RELIABILITY: History obtained from the patient, and EMR.

HISTORY OF PRESENT ILLNESS: This is a 28-year-old Hispanic male that was brought to the ED by his girlfriend. Patient has had a 3+ day stated fever accompanied by diarrhea and shortness of breath. Patient was at a family party a three weeks ago, where he later learned an aunt had tested positive for COVID-19. Patient started having a cough so decided to get tested by an outside lab 7 days ago. Stated he was informed he was positive yesterday. Patient has been mildly symptomatic with a cough up until 3 days ago where he began having chills and became febrile. He now reports diarrhea x2 today, difficulty breathing, and productive cough. He is currently in the ED. Girlfriend is retrieving testing confirmation from apartment. FULL CODE

PAST MEDICAL HISTORY: Obesity, chicken pox (4yrs old), broken leg 2010, depression treated by PCP.

PAST SURGICAL HISTORY: Appendectomy 2016, Tonsillectomy/Adenoidectomy approximately 23yrs ago.

SOCIAL HISTORY: Single. Lives in apartment with girlfriend. Denies tobacco, illicit drugs, or vaping. Drinks socially 4-5 drinks/month. Employed at Amazon full time.

FAMILY HISTORY: Father has HTN, DMII, obesity. Mother had breast cancer 2015 both alive in their late 50’s. Two brothers in good health, no children.

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This study source was downloaded by 100000800518114 from CourseHero.com on 12-15-2021 07:43:31 GMT -06:00
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https://www.coursehero.com/file/65712889/H-and-P-2docx/
)

MEDICATIONS: Celexa dose unknown daily for depression. Melatonin 5mg as needed for sleep at night.

ALLERGIES: Seasonal, shellfish

REVIEW OF SYSTEMS:

CONSTITUTIONAL: SOB, chills, febrile, HEAD AND NECK: Reports headache

CARDIOVASCULAR: denies chest pain or palpitation, reports diaphoresis RESPIRATORY: Reports difficulty breathing, productive cough, denies hemopytosis GASTROINTNTESTINAL: Reports diarrhea x 2, denies blood in stools, reports nausea GENTINOURINARY: Denies urgency, denies foul odor

MUSCULOSKELETAL: Reports joint and muscle pain NEUROLOGIC: Reports weakness, Denies syncope, dizziness PSYCHOLOGIC: Reports depression IMMUNOLOGIC/ALLERGY: Denies bruising or bleeding INTEGUMENT: Denies s

Admission History and Physical

ANP 652: Robin McLinn

Patient Name: A.S. DOB: 03/15/1992

Provider: ACNP Student Robin McLinn RM#: ED #14

ADM: 07/14/2020 Patient Type: Tele Inpatient

CHIEF COMPLAINT: Chief Complaint: “I have had a fever for 3 days with diarrhea starting today, I feel really tired and can’t catch my breath. I had a COVID 19 test come back positive from an outside lab”

RELIABILITY: History obtained from the patient, and EMR.

HISTORY OF PRESENT ILLNESS: This is a 28-year-old Hispanic male that was brought to the ED by his girlfriend. Patient has had a 3+ day stated fever accompanied by diarrhea and shortness of breath. Patient was at a family party a three weeks ago, where he later learned an aunt had tested positive for COVID-19. Patient started having a cough so decided to get tested by an outside lab 7 days ago. Stated he was informed he was positive yesterday. Patient has been mildly symptomatic with a cough up until 3 days ago where he began having chills and became febrile. He now reports diarrhea x2 today, difficulty breathing, and productive cough. He is currently in the ED. Girlfriend is retrieving testing confirmation from apartment. FULL CODE

PAST MEDICAL HISTORY: Obesity, chicken pox (4yrs old), broken leg 2010, depression treated by PCP.

PAST SURGICAL HISTORY: Appendectomy 2016, Tonsillectomy/Adenoidectomy approximately 23yrs ago.

SOCIAL HISTORY: Single. Lives in apartment with girlfriend. Denies tobacco, illicit drugs, or vaping. Drinks socially 4-5 drinks/month. Employed at Amazon full time.

FAMILY HISTORY: Father has HTN, DMII, obesity. Mother had breast cancer 2015 both alive in their late 50’s. Two brothers in good health, no children.

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1
)

(
This study source was downloaded by 100000800518114 from CourseHero.com on 12-15-2021 07:43:31 GMT -06:00
) (
https://www.coursehero.com/file/65712889/H-and-P-2docx/
)

MEDICATIONS: Celexa dose unknown daily for depression. Melatonin 5mg as needed for sleep at night.

ALLERGIES: Seasonal, shellfish

REVIEW OF SYSTEMS:

CONSTITUTIONAL: SOB, chills, febrile, HEAD AND NECK: Reports headache

CARDIOVASCULAR: denies chest pain or palpitation, reports diaphoresis RESPIRATORY: Reports difficulty breathing, productive cough, denies hemopytosis GASTROINTNTESTINAL: Reports diarrhea x 2, denies blood in stools, reports nausea GENTINOURINARY: Denies urgency, denies foul odor

MUSCULOSKELETAL: Reports joint and muscle pain NEUROLOGIC: Reports weakness, Denies syncope, dizziness PSYCHOLOGIC: Reports depression IMMUNOLOGIC/ALLERGY: Denies bruising or bleeding INTEGUMENT: Denies s

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