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History and Physical Exam: Introduction

In Medicine We Have Lines of Medical Communication:

  1. 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.
  2. 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.
  3. 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

SOAP Notes and H&P

SBAR or Hand-Off Note

Discharge Summary

Procedure Note

NBME Clinical Encounter Note

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