History and Physical: a resource for students, residents, and fellows

How to do an H&P, a consult, and every other note you have to write

A practical documentation guide for medical students, interns, residents, fellows and attendings on the wards.

Last reviewed August 2026 | About this site

Free Patient Medical Tracking Forms

Printable scut sheets and patient tracker templates, in the order you present.

Why paper still wins The case for the scut sheet

The chart is the legal record. The sheet is your working memory for the next four hours. You cannot carry a workstation into every room at 5:40 in the morning, and you cannot look at a screen and at a patient at once. Paper folds into a pocket and never logs you out mid sentence.

The sheet is also where you write what you have not entered yet: the potassium the nurse read to you in the hallway, the family meeting moved to two o'clock, the bumped CT.

And pre-rounding is a memory exercise. Nobody holds fifteen data points on eight patients in their head. A printed grid turns recall into recognition, and an empty box means you did not look.

The sheet is not the chart

Nothing on it counts as documentation. Anything clinically important belongs in a note, an order, or a conversation with whoever has to act on it. Local policy governs.

The sheets

All of these are free PDFs. Print them double sided, fold them into your pocket, and stop rewriting the same information three times a day.

For students

  • PDFNew patient admit sheet

    Use this sheet to capture the pertinent information on a new patient. It is laid out in the right order for morning rounds, so you can read straight from it in the proper order and format. No need to prepare a separate report.

  • PDFPatient daily progress note

    Formatted in the right order for morning rounds. Just read down the list. No need to reformat anything before you present.

For residents

  • PDFPatient tracker sheet

    Keeps track of a single patient from the moment you first meet them through daily tracking. Includes an active problem list, space for notes, and separate columns for home and hospital medications.

  • PDFPatient tracker sheet, no grey guides

    The same sheet as above, without the grey guide shading. Better if your printer is temperamental or you prefer a cleaner page.

  • PDFNew patient tracker sheet

    More room for daily tracking and labs. This one seems to be the favorite.

  • PDFMultiple patient tracker sheet

    Ten patients on a single sheet. Great for residents carrying a bigger list who do not have time to fill out a long tracking form for every patient. Gives you a quick view of everybody at once.

  • PDFCardiology and telemetry progress note

    This is how you should write up patients on the telemetry floor or cardiology consults. The more of this information you include, the more complete your workup will be.

One patient or ten Picking a format

One patient per sheet

The Patient tracker sheet and the New patient tracker sheet give a whole page to one person: problem list, home meds beside hospital meds, several days of labs. Use them as a student with three patients, in the ICU, and on anyone with a drip and three consultants. The no grey guides version prints the same layout unshaded.

Ten patients per sheet

The Multiple patient tracker sheet is the resident sign out sheet format: one row each, the summary line, today's issues, what you are waiting on. Carry it with twelve patients and forty minutes. Back it with a full page on the sick two.

Admission day, then every day after

The New patient admit sheet is in presentation order, so the history you take is already arranged the way you will say it. After that, the Patient daily progress note is your rounding sheet, or on telemetry the Cardiology and telemetry progress note, which prompts for what gets forgotten: rhythm, weight, ejection fraction.

Running a sheet through the day

A sheet pays off only if you write on it four separate times. Most people fill one in at 5 a.m., never look at it again, and blame the format.

Signout, the night before

What does not change overnight: name, age, room, summary line, code status, allergies, problems, lines, day of antibiotics. Add what the night team is watching for, so you can ask by name instead of "anything happen?"

Pre-rounding

Data only, in the order below. Interpretation goes in the plan box.

During rounds

In the margin, not the boxes. Every order changed, every consult requested, every study to order, each with a checkbox. An unchecked box at four in the afternoon is what you were about to forget.

Afterwards

Transfer it: subjective, vitals, labs, plan, the order the sheet is printed in. See the progress note guide. Then rebuild it for signout, because the list you hand over at seven is not the one from five.

The pre-rounding sequence

Same order every morning, every patient. Each step tells you what to look for in the next.

  1. Vitals and overnight events first. Ranges, not the 6 a.m. number. A temperature of 38.9 at three in the morning changes everything that follows. So does one systolic of 82.
  2. Ins and outs, and the weight. Before the labs, because if the patient is 3 kilograms up and 2 liters positive you already know what the sodium and creatinine mean. Afterwards, you just explain them with a story you picked first.
  3. The new labs. Trends, not values. Write today's creatinine beside yesterday's. A creatinine of 1.6 is normal or an emergency depending on what it was yesterday.
  4. Then examine the patient. Now you know what to examine for. You walk in knowing the oxygen requirement went up, so you listen to the bases and mean it. Going in cold produces a normal exam on a sick patient.
  5. The plan last. In the room, while the exam is still in your hands. One line per problem. If you cannot write one, that is your question for rounds.

What nobody tells you to write

  • The family phone number, and who the decision maker is. Not "daughter." Her name, her number, and whether she is the one who signs. At eleven at night you will not be working out which of four children to call.
  • Which consultant you are waiting on, and since when. "GI, asked Tuesday a.m." A consult pending two days is a problem. One with no date beside it is invisible.
  • The pending study. The MRI, the culture at 24 hours, the biopsy read. Anything ordered and not seen goes on one running list.
  • The one thing you promised the patient. That you would ask about the home gabapentin dose, or call the wife. Patients remember every promise, and keeping the small ones is most of what they mean by a good doctor.

Privacy and PHI

A note on patient privacy

These sheets hold protected health information the moment you write on them. Keep them on your person, do not leave them on a workroom desk, and shred them at the end of the rotation rather than dropping them in a recycling bin.

Two more habits. Never photograph your list. A picture of a sign out sheet is a disclosure to a phone, a backup and a cloud account, and one of the fastest ways a trainee gets into real trouble. Do not text it either.

Check your scrub pockets before the laundry, because that is where lost lists come from. If you lose one, report it the same day. That is a bad afternoon. Concealing it is a much worse year.

Get the printable tracker sheet pack

These are the printable PDF scut sheets we use on the wards: admit sheets and daily progress notes laid out in the exact order you present on rounds, patient trackers with an active problem list and separate columns for home and hospital medications, a ten patient sheet for bigger lists, and a cardiology and telemetry note. Print them double sided, fold them into your pocket, and stop rewriting the same information three times a day.

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