How to correctly do an Admission History and Physical
Below is an explanation of how to do an H&P with an assessment and plan guide.
CC: When you are doing your H&P for inpatient medicine, this should be their admitting diagnosis and should answer the question, "Why is this patient being admitted?" Why are they so sick that this has to be treated inside the hospital, i.e. "inpatient". This should not be your typical "what the patient said to you when they walked in" type of chief complaint. That is for the first physician seeing them, usually the ER physician or at their family practice clinic. For example, the chief complaint should never be, "I have been short of breath for 2 days". That is what they told the ER doctor. Your chief complaint should be, "Asthma Exacerbation".
Examples of chief complaints that are useful for Admission History and Physicals:
Severe Asthma Exacerbation, COPD Exacerbation, Hypoxic Respitory Failure, Sepsis, Altered Mental Status, CVA, NSTEMI, STEMI, Atypical Chest Pain, Upper GI Bleed, Left Ventricular Systolic Dysfunction (CHF), etc, etc.
All of the above quickly answer the question, "Why do they need to be in the hospital?" And all are good reasons to be hospitalized. If you don't know what the chief complaint is, finish your H&P and by the time you are done, you can come back and figure out what to call this patient.
If the patient was a book, think of the CC as the title of the book. A one word summary of the patient. "Massive Pulmonary Embolism" or "NSTEMI" or "Cardiac Arrest". A quick summary of why they are here.
If this is a consult, the Chief Complaint should answer the question, "Why are we being consulted?" It should really be "RFC" or Reason For Consult. A few examples could be; Acute Renal Failure, Upper GI Bleed, Respitory Failure, Sepsis, etc. See the Consult guideline for more information.
HPI: The HPI should tell the story of the patient from the time they hit the door (if they came in through the ER) to the moment you are seeing them. If they are a direct admission, it should describe their whole outpatient story and what was tried, leading up to why they are being admitted. For a consult, the HPI should tell the story of the patient up until the point of why you are being consulted. What did the primary attending or team try before consulting you? What has been the hospital course for this patient? When did they receive contrast? Times, dates, interventions, and the reason for consult are important. The HPI is the story of the patient. It is the most useful bit of information. It should answer the questions you have all been taught about; onset, duration, location, radiation, alleviating, aggravating, etc, etc. For more detail on a consult, see the Consult Guide.
The HPI is the history of PRESENT illness. Not a past medical history. Too many times you see students and residents (and even attendings) writing out, "This is a 54 year old asthmatic, diabetic, hypertensive, osteopenic patient that presents with a three day history of shortness of breath". That is poor form. What if their shortness of breath is positional, and gets worse when they lie down? What if it is heart failure this time and not their asthma? By stating that "this is a 34 year old asthmatic" you have biased your HPI towards thinking it is the asthma. Stop doing this immediately! This is the single biggest mistake seen on H&Ps. There is a section on the H&P called "Past Medical History" that is where their history should go!
Once again, please do not include the past medical history in the history of PRESENT illness section. Stop biasing your current history taking with old historical information. You can synthesize and use their history later. In this particular part though, just the present symptoms. If you do this correctly, you should easily be able to figure out if the shortness of breath is from heart failure or asthma. Leave the past medical history to the past medical history section!
The HPI should end up being the longest section with many details. You can discuss any recent changes in medications as well. For example, if a patient comes in complaining of lightheadedness and had her blood pressure medications increased last week, that is very relevant.
Of course, some attendings may want you to present a patient in a certain way. Please do it as they request, however know in the back of your mind that you are doing it wrong. When you are the boss, you can do it however you want. Plus you will get paid more if you do your H&Ps properly and address the HPI by itself and the PMH by itself.
PMH: Here you list patient's on-going medical problems. If they are 80 years old and had a toenail infection when they were three years old, it's probably not useful. Please include useful, on-going medical problems and a list of surgeries. If something is recent or pertinent to the current (present) illness, please add more detail. If the patient had open heart surgery last week, and they come in today complaining of chest pain, simply listing "CABG" as some past event that may have happened 20 years ago, is not good enough. Include dates and time of pertinent items, if they are pertinent to the current complaint. Also, chronic problems should be addressed as to whether or not they are well controlled, uncontrolled, etc. Especially, if they pertain to the current illness.
FH: Family history is important in many medical instances. If a 30 year old patient comes in with chest pain, it's important to know that all his brothers died of a heart attack by age 35. However, the fact that mom had breast cancer is probably not as useful. Use your intuition and figure out what needs to be asked. Do not write "Non-contributory". I hate that term, and it just means you didn't ask. If you want to get paid for asking a family history, you can write, "Asked about family history and family history is not contributing to the current illness." Then you can bill a level five H&P. If you are a resident, do your attendings a favor and dictate it correctly so they can get paid appropriately.
Soc: Yes, social history matters. It's not just "negative times three". That means you didn't ask. Social history matters in terms of exposures, travel, the type of work they do, and what their lifestyle consists of. Don't skip this section. If they are here for hyponatremia or altered mental status, get more details on their lifestyle, drinking habits, sexual history, travel history, etc. Use your intuition. Not every 80 year old grandmother needs a sexual history.
All: This is where you list their allergies, and what their reaction may have been. This is especially important if this is an asthma exacerbation or anaphylaxis. I always list allergies before medications. It just makes more sense.
Meds: If this is an admission H&P, then here you list all their outpatient medications and any recent changes in doses or medications. If this is a consult, you list the current medications they are on in the hospital and dates of changes in doses or additions of new medications. See the Consult Guide.
ROS: This is a 14 system review. You all know what this is and you can do it however you like. Start from the top with the patient's head and make your way down to their toes. If you don't find anything, you should dictate this as, "14 systems reviewed and otherwise negative" so you can get paid for doing a complete history and physical.
Some patients talk a lot and will start to agree with everything that you ask them on ROS. You should focus your questions to the usual suspects that seem to be pertinent to this patient's primary complaint. Of course, the more thorough you are the better, since the whole point of the review is to ferret out any issues that may not have been discovered in the HPI. The more thorough you are the better, but don't go overboard.
PE: The physical exam always starts with the vitals, list these, then do your system by system exam. You all know how to do this. If they are an ICU patient or critically ill, list the vitals as ranges, and include ins and outs, as well as drains. If they were dialyzed, note the amount of fluid that was ultra-filtrated off. Be thorough if the patient is sicker!
Lab work and Imaging: Here you can list the pertinent labs and imaging results. Do not circle any abnormal lab values. Everyone knows they are abnormal. Sometimes you see students and residents circling an elevated glucose or low sodium. This is a medico legal nightmare. Any jury looking at your H&P will think that all you cared about was the elevated glucose and low sodium, while ignoring the elevated tropinin and extremely low bicarbonate level. Do not do this! You will open yourself up to many problems. And it looks childish too.
Assessment and Plan: So far, everything above, a monkey could do. Anyone can be trained to do the above very well. It is just a matter of asking a bunch of questions and writing down the answers. The A&P is how you get paid. This is the money portion of medicine. This is where you show your stuff! This is where other physicians look to see what you think the patient has, and how you plan to treat them. This is where a resident or student can shine (or falter). This is how we can tell how dumb or smart you are
The A&P should be a list of ACUTE issues. It should answer the question, why must this patient be admitted? It should not be a regurgitation of their past medical hisroty. It is for ACUTE issues that can not be dealth with outside of a hospital. Why is it so ACUTE that the patient has to be inpatient? You have to justify the admission, not list old problems. Avoid listing old problems unless they are actively being addressed.
Of course, there are many ways to do the A&P section. Some like to list their entire assessment first, then list their entire plan. This creates two separate lists. This works for billing and quickly shows the number of problems (assessments) that a patient has, as well as how you plan to treat the patient in general. The more complicated the patient, the more decision making you have to make, the more you can get paid. Hence, it is in your best interest to have a long assessment of all of the problems the patient has, in order to demonstrate a high level of complexity, so you can be paid more.
Please DO NOT list things like "History of UTI" and "History of alopecia" and "History of ORIF of tibia" and "History of C-section" and "History of CABG". The Assessment and Plan should be a list of CURRENT, ACUTE problems, and what you are doing to fix them. It should not be a reiteration of their past medical history. The current, acute assessment should include things that can only be treated in the hospital, not their entire history. Unless of course, they had CABG last week, and are in for a NSTEMI today. That would be pertinent to know, but still can be in the PMH, unless you are calling that CT surgeon or consulting them to help with this case. Do not list a ton of items as "history of X" in an attempt to build your case for a higher level of decision making or higher level of care, you aren't going to be paid more for creating a blaoted list of old, non-active issues. History belongs in history section. This section is for their current, acute problems, and how you are treating them.
Another way to do it, which I prefer, is to list each problem, starting with the most acute as number one, and the intervention or plan you plan on doing for that problem underneath it. Then move on to the second problem, and it's plan. This seems more appropriate since you list the problems and their plan along with them. It makes more sense. It's also easier for others reading your H&P or consult to figure out what you plan on doing for each problem. Below are some examples:
1. Hypercapnic respitory failure
4. Acute on chronic kidney disease
1. Ventilator support
2. IV Steroids
3. IV Hydration
4. Blood, sputum, urine cultures
5. ABGs Q4
6. NEBS Q4 and PRN
7. Foley, strict I/Os
An example of the method I prefer:
Assessment and Plan:
1. Hypertensive Emergency- continue nitro drip. Maintain BP 140-180 systolic. Restart PO meds tomorrow. Neurology following. Follow up CT scan in AM.
2. Hypertensive Encephalopathy- likely secondary to above. BP control. Restart PO Meds.
3. Reactive Leukocytosis- acute phase reactant due to above. Monitor.
4. NSTEMI- elevated troponin 17.8. Start aspirin, plavix, lipitor 80mg PO, lovenox 30mg IV and 1mg/kg SC, reopro IV, tele monitoring, O2 by NC to maintain SpO2 of 100%. ACEI before discharge. Cardiology following. Likely cath when stable. Troponin X3 Q6 hours apart with EKGs.
This just flows better and it's obvious what you are thinking and doing for each issue. You can also have your medical students list the drugs that go with each problem as well in that section. This is a great teaching tool that lets the students know that these drugs treat that problem.
See also the Consult Guide for information on how to do a consult properly.
Progress (SOAP) Note
Cardiology Progress Note and Consult
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