MEDICINE: H&P TEMPLATE
HPI:
ROS: Please be sure to capitalize and put a + sign in front of what is positive, this way it will stand out and make this
section of your note easier for people to interpret!
Gen: no loss or gain of weight, no fatigue, no fevers, chills, night sweats
Eyes: no recent changes in vision, no blurred vision or diplopia; wears corrective lenses?
Ears: no recent changes in hearing, no tinnitus
Nose: no nosebleeds
Mouth: no bleeding gums, sore throat
Allergies: no congestion
Neck: no pain or stiffness
Resp: no SOB, no cough
CV: no palpitations, no chest pain
GI: no changes in appetite, no dysphagia, no n/v, no abdominal pain, no diarrhea, no constipation, no BRBPR or melena
GU: no dysuria
Neuro: no weakness, no numbness, no dizziness, no balance problems, no headache, no seizures, no trouble swallowing
(dysphagia), no trouble speaking (aphasia or dysarthria), no confusion, no b/b incontinence
Skin: no rashes
MSK: no joint pain
Heme: no easy bruising, no bleeding
PMH:
PSH:
FH:
SH:
Lives with:
Occupation:
T:
E:
D:
ALLG: NKDA
MEDS (outpt): Do not just list medication names, list dosing and timing too!!!
PHYSICAL EXAM:
VS: ***If your pt is on a vent, state vent settings after O2 sat (TV, RR, FiO2, PEEP)!
DRIPS:
DRAINS:
UOP:
GEN: NAD, A&Ox3
HEENT: NC/AT, no scleral icterus, PERRL, EOMI, mmm, no lymphadenopathy
CV: rrr, no m/r/g, no carotid bruits, no JVD
RESP: CTAB, no wheezes/rhonchi/crackles
ABD: soft, NT/ND, +BS, no HSM
EXT: WWP, no c/c/e
NEURO: CN 2-12 grossly intact, no focal deficits appreciated, MAEW, sensation to light touch grossly intact,
2+ patellar tendon reflexes BL
MEDS (inpt): For abx PLEASE remember to put the start and stop date!!!
LABS: Please remember to TREND your labs, one day’s lab values isn’t very helpful (unless these are the admit labs).
IMAGING: It’s okay to just put the “impression” here, but please be sure to read the whole report! Sometimes important
findings that you would want to include in your note are not mentioned in the impression. Be aware of this!
ASSESSMENT & PLAN:
*Organize by problem list if patient is on wards, organize by organ system if ICU patient (see systems below)…
NEURO:
CV:
RESP:
FEN/GI:
GU/RENAL:
HEME:
ID:
ENDO:
MSK:
CODE STATUS: PLEASE REMEMBER TO ALWAYS DOCUMENT YOUR PT’S CODE STATUS!!! ESP IN ICU!!!