H&P template: history and physical, with a complete example
A history and physical (H&P) is the complete note written when a patient is new to you or admitted: chief complaint, history of present illness, past history, medications, allergies, family and social history, review of systems, examination, assessment and plan. Below is an H&P template to copy, a complete example, and how Scripta drafts one from the visit.
Transcription and the draft note are usually ready within 1–3 minutes of pressing Stop; the note itself takes about 20–40 seconds.
Last updated Scripta by SyncEdge
Scripta drafts documentation of what was said in the visit; the clinician reviews, edits and signs; it does not diagnose.
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What sections does an H&P include?
Ten, in this order: chief complaint, history of present illness, past medical and surgical history, medications, allergies, family and social history, review of systems, physical examination, assessment and plan. Together they give the next clinician the whole picture.
- Chief Complaint
- The main reason for the visit, briefly, in the patient's words where possible.
- History of Present Illness
- The story of the current problem in order: onset, duration, character, severity, what changes it, associated symptoms and what has been tried.
- Past Medical and Surgical History
- Previous illnesses, chronic conditions, operations and hospital admissions that were mentioned.
- Medications
- Current medicines with dose and frequency exactly as stated, including supplements, herbal remedies and shop-bought pills.
- Allergies
- Drug and other allergies with the reaction, exactly as stated; an explicit denial is recorded as a denial.
- Family and Social History
- Relevant family history; smoking, alcohol, other substances, occupation and living situation, as discussed.
- Review of Systems
- Symptoms asked about, body system by body system, including the pertinent negatives the patient stated.
- Physical Examination
- Vital signs and examination findings stated aloud during the visit, and nothing else.
- Assessment
- The clinician's stated impression and differentials only.
- Plan
- Investigations, treatment with exact doses, advice, referrals and follow-up, as stated.
What does a complete H&P look like? An example with epigastric pain
Below is a full H&P Scripta drafted from an invented first visit: a rice farmer with burning epigastric pain after a week of shop-bought mixed pills and ibuprofen. Note the sections that say not discussed, and the Please verify list.
Chief Complaint
Burning pain at the top of the stomach for 3 days.
History of Present Illness
Three days of burning epigastric pain, worst on an empty stomach and easing a little after eating. Nausea, with two episodes of vomiting yesterday (water and rice), no blood or dark material. No black stools.
For the past week has been taking mixed pills from a village shop for back pain from heavy farm work, plus ibuprofen when the pain is severe.
Past Medical and Surgical History
- Hypertension
- Surgery and hospital admissions not discussed
Medications
- Amlodipine 5 mg once daily
- Mixed pills from a village shop, one packet each time, for 1 week (4-5 pills per packet, yellow and white, identity unknown)
- Ibuprofen 400 mg, one tablet each time when back pain is severe
Allergies
Once had an itchy rash after a medicine; cannot recall which.
Family and Social History
- Works in the rice fields (heavy work)
- Drinks rice whisky with friends 2-3 times a week
- Family history and smoking not discussed
Review of Systems
- GI: epigastric burning, nausea, vomiting twice; no vomiting of blood, no black stools
- MSK: back pain
- Other systems not asked
Physical Examination
- BP 132/84 mmHg, pulse 88, temperature 37.1 °C
- Abdomen: epigastric tenderness; no right lower quadrant tenderness
Assessment
Gastritis, or possibly a stomach ulcer, from the mixed pills and ibuprofen.
Plan
- Stop the mixed pills and ibuprofen.
- Omeprazole 20 mg once daily before breakfast for 4 weeks.
- Paracetamol 500 mg, 1 tablet every 6 hours as needed for back pain.
- Advised to stop drinking alcohol.
- Return to hospital immediately if vomiting blood, passing black stools or pain gets much worse.
- Follow-up in 2 weeks.
Please verify (shown to the clinician, not part of the note)
- How often the mixed pills and ibuprofen were taken was not stated ("one packet each time", "one tablet each time").
- Contents of the mixed pills are unknown (4-5 pills per packet, yellow and white).
- Allergy history incomplete: itchy rash after a medicine the patient cannot name.
- Amount of alcohol per occasion was not stated.
The same consultation as a shorter SOAP note.
How should medications and allergies be documented?
Exactly as the patient states them. Write each medicine with its dose and how often it is taken, including herbal remedies and pills bought over the counter, and record each allergy with the reaction. If the patient denies allergies, write the denial; if they cannot remember, say so.
- Unknown medicines stay unknown: "mixed pills from a village shop, 4-5 per packet, yellow and white, identity unknown" is more useful than a guess.
- Ask the patient to bring the packets or a photo of what they take; a pharmacy can often identify a mixed-pill packet.
- An allergy with no named drug is still an allergy: record the reaction and follow it up until the drug is known.
- Scripta flags a dose without a frequency, or an allergy without a drug name, rather than completing it.
What if something wasn't asked or examined?
Write that it was not asked or not discussed, and leave it at that. An H&P that fills in normal findings for systems nobody examined looks complete but says something untrue.
Scripta follows that rule. In the example, "Surgery and hospital admissions not discussed", "Family history and smoking not discussed" and "Other systems not asked" are written out plainly, so the gaps are visible to you and to the next reader.
H&P or SOAP note: which do I need?
Write an H&P when the patient is new to you or being admitted and the record needs the full history and examination. For a focused visit about a known problem, a SOAP note is shorter and easier to read.
- An admission note is the H&P written when a patient is admitted; it uses the same sections.
- Follow-up visits after that: a progress note.
How should I run the visit so the H&P comes out complete?
Cover the history in roughly the order you want it charted, and say examination findings aloud as you go. Scripta can only fill sections from what was said, so the more of the H&P you speak, the less you type later.
- Start with the chief complaint in the patient's own words, and let them tell the story before you ask closed questions.
- Ask directly about medicines, including herbal remedies, supplements and shop-bought pills, and about allergies and the reaction.
- Ask pertinent negatives out loud: "Any vomiting of blood? Any black stools?" Only the answers the patient gives are recorded.
- Cover family history, smoking and alcohol; if you skip them, the note says so.
- Call out vital signs and examination findings by system as you examine.
- Close with your impression and plan, spoken to the patient or to a colleague.
How does Scripta write an H&P from a recording?
It drafts all ten sections from the transcript of the visit alone. Sections the conversation did not cover are written as not discussed, and anything uncertain, such as a dose without a frequency, goes into the Please verify list.
- Headings stay in English in any note language; the body follows the note language you choose.
- Doses, numbers, units and dates are copied as spoken, never rounded or completed.
- When the visit is linked by HN to an earlier note, that note is used only for continuity, never as today's findings.
- You review it, edit it or redraft it by instruction, then copy the H&P into your HIS or EMR.
- Patients can speak Thai, Thai mixed with English, or Isan, Northern or Southern Thai: Scripta accepts the speech, writes the note in standard Thai (or English, if you choose), and flags any word it isn't sure of for you to check.
Copy the H&P template
A blank history and physical with the same ten headings and the prompts Scripta uses. Paste it into your system and fill it in, or record the visit and let Scripta draft it.
Chief Complaint Main reason for the visit, in the patient's words: History of Present Illness Onset, duration, character, severity, what changes it, associated symptoms, what has been tried: Past Medical and Surgical History Illnesses, chronic conditions, operations, hospital admissions: Medications Name, dose, frequency (include supplements, herbal remedies, shop-bought pills): Allergies Drug or substance, and the reaction (or an explicit denial): Family and Social History Relevant family history; smoking, alcohol, other substances; occupation; living situation: Review of Systems By system, with pertinent negatives the patient stated; write "not asked" for systems not covered: Physical Examination Vital signs; findings by system: Assessment Impression and differentials, in the clinician's words: Plan Investigations, treatment with exact doses, advice, referrals, follow-up:
Frequently asked questions
What do CC, HPI, PMH and ROS stand for?
CC is the chief complaint, the main reason for the visit. HPI is the history of present illness, the story of the current problem. PMH is past medical history. ROS is the review of systems, the symptoms asked about body system by body system.
Is an admission note the same as an H&P?
In practice, yes: the admission note is the H&P written when a patient is admitted to hospital. It uses the same sections, from chief complaint to plan, and hospitals may add their own, such as code status or the admitting team. Later inpatient days are documented in daily progress notes.
What are pertinent negatives?
Symptoms the patient does not have that matter for your thinking, such as "no vomiting of blood, no black stools" in epigastric pain. Scripta records them only when the patient actually said so, and never fills in negatives for systems that were not asked about.
Can Scripta write an H&P from a recorded new-patient visit?
Yes, as a draft. Choose History and Physical before you record or when you create the note. Every section is filled from the conversation; anything not covered, such as surgical history that never came up, is marked as not discussed.
Can the H&P be in Thai?
Yes. The headings stay in English (Chief Complaint, History of Present Illness and so on), with the body in Thai and drug names, doses and abbreviations in their usual form, the way Thai charts are written. You can also have the whole note in English.
How long does an H&P take to write?
By hand, an H&P often takes longer than the consultation itself. With Scripta the draft is written in the background while you see the next patient, usually within 1–3 minutes of pressing Stop, so your time goes on reviewing it and fixing what the Please verify list points out.
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