Assignment: Academic Clinical History and Physical Note

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.

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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 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 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 swallowing or inability to taste.
CARDIOVASCULAR: These are answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the fingers or toes, edema, leg pain when walking.

RESPIRATORY: These are the patient’s answers about signs or symptoms of the respiratory Some examples may be cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath, difficulty breathing.
GASTROINTESTINAL: These are patient’s answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus, frequent nausea or vomiting, abdominal swelling, changes in bowel habits or stool characteristics, such as diarrhea or constipation.
GENITOURINARY: These are the patient’s answers about signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses, toilet training, or bedwetting.
MUSCULOSKELETAL: These are the patient’s answers about signs or symptoms of the musculoskeletal system. Examples include muscle cramps, twitching or pain, limitations on walking, running, or participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint
INTEGUMENTARY: These are the patient’s answers about signs or symptoms of the skin. Some examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesions, nail color or texture, breast pain, tenderness or swelling, breast lumps, and history of nipple discharge or
NEUROLOGICAL: These are the patient’s answers about signs or symptoms of the neurologic system. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions, memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability to concentrate, sensory disturbances, motor disturbances, including gait, balance, and coordination, tremor, or paralysis.
PSYCHIATRIC: These are the patient’s answers about signs or symptoms of the psychiatric Some examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment, restlessness, irritability, and excessive mood swings.
ENDOCRINE: These are the patient’s answers about signs or symptoms of the endocrine system. Some examples may be blood sugar readings at home, sudden changes in height or weight, increased appetite or thirst, intolerance to heat or cold, and changes in hair distribution or skin pigment.
HEMATOLOGIC/LYMPHATIC: These are the patient’s answers about signs or symptoms of the hematologic/lymphatic Examples include easy bruising, fevers which come and go, swollen glands, night sweats, and unusual bleeding.
ALLERGIC/IMMUNOLOGIC: These are the patient’s answers about signs or symptoms of allergic/immunologic issues. Examples include answers about allergies to medication, foods or other substances, hives or itching, frequent sneezing, chronic or clear postnasal drip, conjunctivitis, history of chronic infection, etc.

Physical Exam: What you identify as you assess the patient.

GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress.
VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula, weight, and BMI.
HEENT: Normocephalic and No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear.
NECK: Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness.
CHEST: Nontender to palpation.
LUNGS: Breath sounds are equal and clear No wheezes, rhonchi, or rales.
HEART: Regular rate and rhythm with normal S1 and No murmurs, gallops, or rubs.
BREASTS: No skin or nipple retractions. No nipple discharges or masses.
ABDOMEN: Soft, flat, and No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass.
GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or The epididymis and cords are normal. The perineum is normal.
GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal.
RECTAL: [Male]. Normal sphincter No masses. Prostate is smooth and nontender and without nodules or fluctuance.
RECTAL: [Female]. Normal sphincter No masses or tenderness.
EXTREMITIES: No cyanosis, clubbing, or
NEUROLOGIC: No focal sensory or motor deficits are Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact.
PSYCHIATRIC: The patient is awake, alert, and oriented Recent and remote memory is intact. Appropriate mood and affect.
SKIN: Warm, dry, and well Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Address surgical wounds and drains.
LYMPHATICS: No cervical, axillary, or groin adenopathy is

Laboratory and Radiology Results: List all data available when seeing the patient’s normal and abnormal results. Include all of the CBC and electrolytes (all elements tell a story).

Assessment: (Provide three references)

Differential Diagnoses: A differential diagnosis are potential diagnoses related to the chief complaint and Provide a rationale for the working diagnosis which is one of the differential diagnoses. Include the ICD codes. List at least three working diagnoses related to the admission or consult and identify one as being the primary diagnosis until ruled out.
Acute and Chronic Medical Conditions: What needs to be addressed while admitted, in order of priority.

Treatment Plan: (Provide three references)

What orders are you starting? What medications with dose and frequency? What consults? Education topics? Discharge plan?

Geriatric Considerations:

Based on the age, address any differences in the treatment if the patient was younger or older.

References: List references in APA format.

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Academic Clinical History and Physical Note – Rubric

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History and Physical Note 10 points

Criteria Description

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

Target 10 points

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

Acceptable 9 points

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

Approaching 8 points

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

Insufficient 5 points

The history and physical note is incomplete or otherwise deficient.

Unsatisfactory 0 points

The history and physical note is not included.

Assessment and Clinical Impressions 10 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)

Target 10 points

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

Acceptable 9 points

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

Approaching 8 points

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

Insufficient 5 points

The assessment and clinical impressions are incomplete or otherwise deficient.

Unsatisfactory 0 points

The assessment and clinical impressions are not included.

Plan and Criteria Incorporation 10 points

Criteria Description

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

Target 10 points

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

Acceptable 9 points

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

Approaching 8 points

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

Insufficient 5 points

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

Unsatisfactory 0 points

The plan component management and plan criteria incorporation are not included.

Peer-Reviewed Articles 5 points

Criteria Description Peer-Reviewed Articles

Target 5 points

Three peer-reviewed articles are included.

Acceptable 4.5 points

N/A

Approaching 4 points

N/A

Insufficient 2.5 points

Fewer than three peer-reviewed articles are provided.

Unsatisfactory 0 points

Three peer-reviewed articles are not included.

Mechanics of Writing 7.5 points

Criteria Description

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

Target 7.5 points

No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.

Acceptable 6.75 points

Few mechanical errors are present. Suitable language choice and sentence structure are used.

Approaching 6 points

Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.

Insufficient 3.75 points

Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.

Unsatisfactory 0 points

Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.

Format/Documentation 7.5 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

Target 7.5 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

Acceptable 6.75 points

Appropriate format and documentation are used with only minor errors.

Approaching 6 points

Appropriate format and documentation are used, although there are some obvious errors.

Insufficient 3.75 points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.

Unsatisfactory 0 points

Appropriate format is not used. No documentation of sources is provided.

Total 50 points

Assignment: Academic Clinical History and Physical Note