How to correctly do an Admission History and Physical

CC Chief complaint

When you are doing your H&P for inpatient medicine, this should be the admitting diagnosis, and it should answer one question: why is this patient being admitted? Why are they sick enough that this has to be treated inside the hospital?

This is not the "what the patient said when they walked in" chief complaint. That one belongs to the first physician who saw them, usually the emergency physician or the family practice clinic. Your chief complaint should never be "I have been short of breath for 2 days." That is what they told the ER doctor. Yours should be "asthma exacerbation."

All of those answer the question "why do they need to be in the hospital?" and all of them are good reasons to be hospitalized. If you do not know yet what the chief complaint is, finish the rest of the H&P. By the time you are done you will be able to come back and name the patient.

If the patient were a book, the chief complaint is the title. A one line summary of why they are here. "Massive pulmonary embolism." "NSTEMI." "Cardiac arrest."

HPI History of present illness

The HPI should tell the story of the patient from the moment 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 the whole outpatient story and what was tried, leading up to why they are being admitted.

For a consult, the HPI should tell the story up until the point you were called. What did the primary attending or team try before consulting you? What has the hospital course been? When did they receive contrast? Times, dates, interventions and the reason for consult all matter. For more detail, see the consult guide.

The HPI is the most useful piece of information in the entire note. It should answer everything you have been taught to ask: onset, duration, location, radiation, quality, severity, timing, alleviating and aggravating factors, associated symptoms.

Once again: do not put the past medical history into the history of present illness. Stop biasing your current history taking with old historical information. You can synthesize and use their history later. In this part, just the present symptoms. Do this correctly and you will usually be able to tell whether the shortness of breath is heart failure or asthma without any help.

The HPI should end up as the longest section, with the most detail. Recent medication changes belong here too. If a patient comes in lightheaded and her blood pressure medications were increased last week, that is not background, that is the story.

Of course, some attendings want a patient presented a particular way. Do it the way they ask. Just know, in the back of your mind, that it is wrong, and that when you are the one in charge you can do it properly. You will also be paid more for doing your H&Ps properly, with the HPI addressed by itself and the past medical history addressed by itself.

PMH Past medical history

Here you list the patient's ongoing medical problems. If they are 80 years old and had a toenail infection at age three, it is probably not useful. List useful, ongoing medical problems and a list of surgeries.

If something is recent or pertinent to the present illness, add more detail. If the patient had open heart surgery last week and comes in today with chest pain, simply listing "CABG" as some event that may have happened 20 years ago is not good enough. Include dates and timing for anything that bears on the current complaint.

Chronic problems should also be characterized: well controlled, poorly controlled, uncontrolled. Especially if they pertain to the current illness.

FH Family history

Family history matters in more situations than people give it credit for. If a 30 year old comes in with chest pain, it is important to know that all his brothers died of a heart attack by age 35. That mom had breast cancer is probably less useful here. Use your judgment and work out what needs to be asked.

Do not write "non-contributory." That term tells the reader nothing except that you did not ask. If you want credit for taking a family history, write something like: "Family history obtained and is not contributing to the current illness." Now it is documented, and you can support a level five H&P. If you are a resident, do your attending a favor and dictate it correctly so the visit can be billed appropriately.

Soc Social history

Yes, the social history matters. It is not "negative times three." That, again, means you did not ask.

Social history matters for exposures, travel, the kind of work they do and what their life actually looks like. Do not skip it. If they are here for hyponatremia or altered mental status, go deeper on lifestyle, drinking habits, sexual history and travel history. Use your judgment. Not every 80 year old grandmother needs a sexual history.

All Allergies

List the allergies and the reaction. The reaction matters, particularly if this is an asthma exacerbation or anaphylaxis, and it matters for telling a true allergy apart from an intolerance.

Put allergies before medications. It simply makes more sense in that order.

Meds Medications

On an admission H&P, list all outpatient medications along with any recent changes in dose or agent.

On a consult, list the medications they are currently on in the hospital, with the dates that doses changed or new drugs were added. See the consult guide.

ROS Review of systems

This is a 14 system review. You know what it is and you can run it however you like. Start at the head and work down to the toes. If you find nothing, dictate it as "14 systems reviewed and otherwise negative," so that a complete history and physical is documented.

Some patients will talk a lot and start agreeing with everything you ask. Focus your questions on the systems that are plausibly related to the primary complaint. The whole point of the review is to surface issues the HPI did not, so being thorough is good. Just do not go overboard chasing positives that mean nothing.

PE Physical exam

The physical exam always starts with the vitals. List them, then work system by system. You know how to do this.

If the patient is in the ICU or critically ill, list the vitals as ranges, and include ins and outs and drains. If they were dialyzed, note how much fluid was ultrafiltrated off. The sicker the patient, the more thorough the exam needs to be.

Lab work and imaging

List the pertinent labs and imaging results.

Assessment and plan The money section

Everything above this point, a well-trained monkey could do. Anyone can be taught to ask a list of questions and write down the answers. The assessment and plan is different. This is the part you are actually paid for. This is where other physicians look to see what you think is going on and how you intend to treat it. This is where a student or resident shines, or does not.

The assessment and plan should be a list of acute issues, and it should answer the question: why must this patient be admitted? It is not a regurgitation of their past medical history. It is for acute problems that cannot be dealt with outside a hospital. You are justifying the admission, not listing old problems. Avoid listing old problems unless they are actively being addressed.

There are two common ways to lay this out.

The first is to list the entire assessment, then the entire plan, as two separate lists. It works for billing and it shows at a glance how many problems the patient has and what you intend to do overall. The more complex the patient and the more decision making required, the higher the level of service you can support. So it is in your interest to document every active problem, in order to demonstrate the true complexity of the patient.

The second way, which I prefer, is to list each problem starting with the most acute, and put the plan for that problem directly underneath it. Then move to the second problem and its plan. It makes more sense on the page, and it is far easier for anyone else reading your H&P or consult to see what you intend to do about each issue.

That format simply flows better, and it makes your thinking obvious. You can also have your medical students list the drug that goes with each problem in that section. It is a good teaching tool, because it links the drug to the indication instead of leaving it floating on a med list.

A complete sample admission H&P H&P example

Rules are easy to nod at and hard to follow at two in the morning, so here is a complete admission note example, written out on one patient: a 62 year old man with an NSTEMI on a background of poorly controlled diabetes and hypertension. Read the HPI first and notice what is missing from it. Doses are illustrative, and your hospital's protocols and current references govern what you order.

The ten mistakes that show up on almost every H&P Fix these first

The same ten failures account for most of the bad notes I read. Each takes a minute to fix.

1. Past medical history in the HPI. "A 62 year old diabetic, hypertensive man with chest pain" says you decided the diagnosis before you finished asking. Open with age, sex and the symptom.
2. A chief complaint copied out of triage. "Chest pain for 3 hours" is what he told the emergency physician. Yours is the admitting diagnosis: NSTEMI.
3. "Non-contributory" family history. It records only that you did not ask, and it will not support the level of service you billed. Write what you asked and found.
4. "Negative times three" social history. Three questions out of ten, and it buries the truck stop diet and the rationed insulin. Write the occupation, exposures, living situation and code status.
5. Circling abnormal lab values. It tells every future reader, a jury included, that those were the only numbers you noticed. Address them in the assessment instead.
6. An assessment that is a second past medical history. "History of hernia repair, history of UTI" pads the list without showing one decision. List only the problems that justify the admission.
7. One block of plan bolted onto the end. The reader has to guess which of seven orders belongs to which of six problems. Put each plan under its problem.
8. An HPI with no times or doses. "Given nitro in the ED with some relief" is useless at 04:00. Write 20:05, two 0.4 mg sublingual tablets, 8 out of 10 down to 2.
9. An exam copied forward or pulled from a template. Charting "pulses intact" on a diabetic smoker whose posterior tibial you never felt for is a false entry in a legal document. Write what you actually found.
10. Plans with no numbers, thresholds or owner. "Monitor blood pressure" and "cardiology to see" give the covering intern nothing to act on. Write the target, the interval and the name.