Medical Transcription Services Company

History-physicals are generally developed at the entry level, the first time the doctor sees and examines a patient. A history is done (what has happened to the patient in the current problem and any relative past history), and the physical examination is ( performed; this information is then dictated. History–physicals may include the headings as listed below. The abbreviation is sometimes used (depending on the client) rather than the full formal heading. In the reports in this Volume, when an abbreviation is used, we have attempted to define its meaning in parenthesis following the heading. Other headings, as you will see, are spelled out and are generally all in capital letters and may or may not be in bold-face type, or underlined, again depending on the preferences of the practice or the hospital.

HISTORY AND PHYSICAL: A main heading only. Note that the history portion relates to the patient's "subjective" account of his/her current condition or illness, whereas the physical portion focuses on the "objective" characteristics or findings of the patient's condition or illness, usually by the physician.

DATE: The date of the examination.

CC (Chief Complaint): What the patient subjectively states is wrong.

HPI (History of Present Illness): What the current disease process or injury is, as related to the chief complaint necessitating this particular workup.

PMH (Past Medical History): What the patient's problems or diagnoses have been in the past, both medical and surgical, and any pregnancy or gynecologic history, if significant, to this workup.

FH (Family History): The immediate family’s medical problems and genetic predisposition to problems or diseases.

SH (Social History): The patient's education, work, marital status, children; habits, such as smoking, drinking, drugs, and may even include hobbies and recreational activities.

ROS (Review of Systems): The review of the systems of the body.

MEDICATIONS: Any medications patient is currently using either prescribed or over the counter.

ALLERGIES: Notable allergic reactions, particularly to medications and food products.

PE (Physical Examination): Main heading. The PE is composed of the following four types of evaluation:

• visual – what is seen;
• auditory or aural – what is heard;
• olfactory – what is sensed by the nose; and
• tactile – what is felt.

The examination should include:

GENERAL: How the patient appears to the examiner.
VITAL SIGNS: Temperature, pulse, respirations, blood pressure, height and weight.
SKIN: Turgor, colon tone, etc.
HEENT: Head, eyes, ears, nose and throat.
NECK: Pulses, thyroid.
CHEST: Includes heart (cardiac), lungs, breasts.
ABDOMEN: Includes exam of the palpable internal organs.
GENITALIA: Male/Female anatomy appearance.
RECTAL: Tone, hemorrhoids.
EXTREMITIES: Arms, hands, legs, feet.
NEUROLOGIC: Neurologic examination/testing.

LABORATORY DATA: Any intercurrent labs, which have been obtained at either the a office, by the referring physician, or the hospital outpatient/inpatient department.

IMPRESSION: Main heading. What the examiner thinks is wrong with the patient. Sometimes this appears as PROBLEM in a PROBLEM-ORIENTED record, listing each problem numerically and discussing it in the order presented.

PLAN: Main heading. The further workup (diagnostic tests, etc.) of the problem(s), what medication or surgery is anticipated, return visits required or anticipated, referral to other providers, etc.

Quick Inquiry
Name
Phone
Email
Description
Type the code shown below

Bookmark-www.brainstormworld.com