History
Physical Examination
Date H&P Performed ____________Admission Date _____________
WNL: Within Normal Limits
Chief Complaint: ___________________________________________
WNL
_________________________________________________________
Mental/Neuro
□ __________________________________________
Present Illness: ____________________________________________
Head/Neck
□ _________________________________________
_________________________________________________________
Mouth/Throat
□ _________________________________________
Past Illness/Medical-Surgical History ___________________________
Breast
□ _________________________________________
_________________________________________________________
Heart
□ __________________________________________
Cardio/Pulmonary _________________________________________
Lungs
□ __________________________________________
_________________________________________________________
Abdomen
□ __________________________________________
Allergies: _________________________________________________
Rectal
□ __________________________________________
_________________________________________________________
Pelvic
□ __________________________________________
Mental Status: □ Alert □ Oriented □ Confused □ Disoriented □ Other
Extremities
□ __________________________________________
_________________________________________________________
Impression/Diagnosis ______________________________________
Psychosocial: □ Non Contributory ____________________________
Family History: □ Non Contributory ____________________________
_________________________________________________________
Plan ____________________________________________________
H&P Update Section (H&P greater than 30 days old: New H&P required)
If H&P completed prior to the calendar day of admission or procedure, complete update below: Check appropriate sections
( ) NO CHANGE to this H&P on day of procedure
( ) CHANGE IN EXAMINATION _____________________________________________________________________________________
Necessity for procedure is still present? □ No □ Yes (If no, explain in progress note)
_____________________________________________________________________________________________________________
Physician Signature
Date
IMMEDIATE OPERATIVE / PROCEDURE NOTE
Date/Name of Procedure: __________________________________________________________
Surgeon: ____________________________________________________ Assistant: ________________________________________
Preoperative Diagnosis: ________________________________________ Postoperative Diagnosis _______________________________
Findings: _____________________________________________________________________________________________________________
Technical procedure performed: ________________________________________________________________________________________
Specimens removed: ____________________________________________ Drains ____________________________ EBL __________
Complications: _____________________________________________________________________________________________________
Physicians Signature: __________________________________________________________________ Date: _______________________
DISCHARGE NOTE
Date: _____________________________________________ Time: _____________________________________________________
Course in hospital: __________________________________________________________________________________________________
Communications: □ None
□ Yes, Describe: ________________________________________________________________________
Home Care Diet: □ Regular □ Other: _____________________________________________________________________________
Activity: □ No restrictions
□ Restricted to: __________________________________________________________________________
Follow up Dr. ______________________________________________________ When: ______________________________________
Physician Signature: ________________________________________________ Date _______________________________________
SHORT STAY FORM
(REV 7/08)