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Template content
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History and Physical (H&P) Identifying Information / Visit Context - Age, sex/gender as documented, encounter setting (clinic, ED, inpatient admission), and historians if other than the patient. Chief Complaint - Patient’s stated reason for presentation in their words when possible. History of Present Illness - Chronologic story: onset, course, severity, associated symptoms, aggravating/alleviating factors, and prior similar episodes. - Pertinent positives/negatives and treatments tried. - Functional impact and patient goals for this encounter. Past Medical History - Active and resolved medical conditions with approximate onset when known. Past Surgical History - Surgeries and dates/complications as available. Medications - Current medications with doses; adherence notes if discussed. Include OTC and supplements when relevant. Allergies - Drug/food/environmental allergies and reactions. Family History - Relevant hereditary and familial conditions (e.g., CAD, diabetes, cancer, psychiatric illness). Social History - Tobacco, alcohol, substances; occupation; living situation; supports; advance directives if discussed. Review of Systems - Constitutional, HEENT, cardiovascular, respiratory, GI, GU, musculoskeletal, neurologic, psychiatric, skin, endocrine, hematologic/lymphatic—as obtained. Note pertinent positives and negatives. Physical Examination - Vital signs and general appearance. - Exam by system as performed; document key negative findings that affect medical decision-making. Data Reviewed - Labs, imaging, ECGs, and outside records reviewed with brief interpretation. Assessment - Problem list with clinical impressions, differentials, and acuity. - Brief reasoning for leading diagnoses. Plan - Diagnostics, therapeutics, monitoring parameters, consultations, disposition, patient education, and follow-up. - Code status / goals of care if addressed.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Follows the classic H&P outline clinicians expect on admission and new-patient charts.
- Keeps PMH, medications, allergies, and social history as first-class sections.
- Supports both ambulatory new-patient visits and inpatient admission documentation.
- Clear assessment/plan scaffolding for problem lists that will carry into daily notes.
- 1Hospital admission H&Ps
- 2New-patient ambulatory evaluations
- 3Pre-operative or consult-driven full assessments
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Chief Complaint “Shortness of breath and leg swelling for 1 week.” HPI 68-year-old with HFrEF (EF 30%) and CKD stage 3 presents with progressive DOE, orthopnea (3 pillows), and bilateral leg edema over 7 days after running out of furosemide 4 days ago. Denies chest pain, fever, or cough productive of purulent sputum. Weight up ~8 lb from last clinic visit. PMH / Meds / Allergies HFrEF, HTN, CKD3, T2DM. Home: carvedilol, sacubitril/valsartan, spironolactone, metformin, atorvastatin; furosemide recently missed. NKDA. Exam BP 148/92, HR 96, SpO2 91% RA → 96% on 2 L NC, weight 198 lb. JVP elevated; bibasilar crackles; 2+ pitting edema to mid-calves. Data BNP elevated vs baseline; CXR pulmonary edema; Cr 1.6 (baseline 1.3); K 4.0. ECG sinus tach, no acute ischemic changes. Assessment 1) Acute decompensated heart failure, likely medication nonadherence. 2) CKD with mild Cr rise. 3) T2DM — monitor glucoses on steroids if used. Plan Admit medicine; IV diuresis; restart GDMT as tolerated; strict I/O and daily weights; low-sodium diet; cardiology aware. Patient education on diuretic adherence. Goals of care: full code per patient.
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2. Record or dictate
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3. Review and sign
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Related templates
Put this template to work on your next visit
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