H&P Framework:
Purpose: The purpose of a good H&P is to organize and present the major presenting
problems such that clear differential diagnoses may be extracted. It should be written
with DSM-IV diagnoses in mind, covering a minimum of these five major areas: 1)
Mood Disorder (Depression [SIG E CAPS], Bipolar [DIG FAST]), 2) Substance Use,
3) Psychosis, 4) Anxiety (GAD, Panic, PTSD [this would implicitly require brief
mention of trauma history] etc) 5) Safety assessment. You may choose to address Axis
II characteristics if pertinent. Overall, this is a diagnostic assessment and should never be
simply a verbatim re-telling of the interview. Your task is to take the interview, break it
down, and create a coherent clinical picture.
HPI:
1st paragraph Identifying information followed by known h/o with most recent IOP admission,
followed by reason and route of presentation with pertinent contextual
information.
 If patient presents with any family note it
 Recent stressors (as specific as possible) impetus for presentation at that time.
 Most pertinent positive symptoms, most pertinent negative symptoms and
timeline. Think specifically of DSM-IV criteria and address directly. Quantify as
you can and use pt quotes if helpful. Think general to specific (i.e. pt is depressed
w/ significant neurovegatative symptoms including insomnia (sleeping 45hrs/night)); here the progression is: depressed-> neurovegative symptoms->
insomnia-> pt quote/quantify.)
 Quotes: A quote should modify/describe a clinically pertinent term. It should
follow a clinical descriptor and should not be used as a stand alone descriptor.
You should think twice about using a quote if it does not describe something
clinical.
 If suicidality, note duration, details of plan, if any action list as detailed as
possible what occurred including what prevented completion, any h/o attempts, if
access to firearms
Example:
Mr. R is a 35 y/o single, unemployed WM c h/o Dep. NOS (MDD vs. SIMD), EtOH
abuse, cocaine abuse, and 1 prior IOP admission in 2/09 who presents via EMS due to
worsening depression c SI with plan to shoot self, in context of substance abuse
relapse. He reports significant stressors of relationship ending, financial instability,
and relapse on cocaine, all occurring over the last 2 months. He reports the specific
impetus for presentation as girlfriend asking him to move out yesterday. He endorses
symptoms of dep. mood, poor sleep (4-6hrs/night), dec. energy, dec. concentration,
anhedonia (“I don’t even like to read anymore”), and SI. Timeline is difficult to
establish but he reports these have been present for at least the past 2 months. He
denies current hopelessness, guilt, psychomotor activation/retardation. Denies any
AVH. Reports suicidal thoughts x 3 days c plan to shoot self. He has not acted on
these impulses and has no h/o attempts. He denies access to firearms.
2nd paragraph If family/friend present put their name, number, and relationship, followed by
their concerns and any additional useful information
 Quotes are great but this needs to be focused to some degree, meaning, don’t put
every thing that comes out down on the HPI
Example:
Pt’s brother, John Smith (843-XXX-XXXX) is present in ER, and reports that patient
has appeared depressed over the last 2-3 weeks, but he has been unaware of any SI or
past attempts. Mr. S reports that he was called by pt. last night stating that he had
been kicked out of house and did not have a place to live. He was concerned for
patients safety and called EMS, who went to girlfriends house and brought pt. to ER.
3rd paragraph –
 Usually I make this substance abuse bc its so commonly a comorbid process in
patients. If substance/detox were the main issue this could be included in the
main paragraph. If substances weren’t involved at all, I would just say “Denies
any EtOH/illicits, Denies any h/o withdrawal.
 If present, attempt to separate each substance into how much, how often, last use,
any h/o withdrawal. Ok to say that specifics can’t be determined and leave things
open.
 Particularly c EtOH/BZD/opiates, put as close a time as possible for last use.
Also put if any prior detox’s or withdrawals.
 If pt. has insight into substances then note it, but if not then doesn’t have to be
pushed in assessment setting. Note that they are pre-contemplative or have no
insight and pass that on to the primary team.
 If you can get details that might differentiate abuse vs. dep. then put them in, but
the more important information in the assessment setting is recent use and risk of
withdrawal. i.e. Sometimes its not practical to screen through the entire EtOH
dep. criteria. This can be done by primary team, but you do need to have an idea
what the patient’s risk of withdrawal is.
Example:
Substance – Reports EtOH use 1-2x week, usually 6-10 beers. Last drink was 2 days
ago. He denies any h/o complicated withdrawal including seizures or DT’s. Denies any
prior EtOH detox. Reports cocaine use as daily over last 2 months after period of 6
months abstinence. Last use yesterday. Difficult to determine exact amount but pt.
reports “at least $100 a week.” Reports occasional powder cocaine usage c
predominately crack cocaine usage. Denies any additional substances. Fair insight at
this time, stating “I think my drug use makes everything worse.”
Additional paragraphs –
 Mania, psychosis, anxiety/panic, and PTSD/trauma all need to be covered. If
there are no symptoms of one of these, then put “Denies any h/o AVH or
psychosis.” Do a screen and if there is a positive assessment then make that a
detailed paragraph with timeline, pertinent pos./neg. symptoms and prior

treatment if this can be attained. If one these fields were the main issue, then
obviously they’de be in the main paragraph. Often they are a major secondary
issue i.e. pt. c dep. who presents c SI also has significant PTSD symptoms or
anxiety/panic symptoms get included c depression. In that situation I would put
them in a second main type paragraph. If there are no symtoms of mania or
psychosis, etc. then I simply put them together and say “Pt. denies any h/o or
current s/s of mania or psychosis.”
Usually I end with an “Of note” paragraph in which I put any additional
information that seems pertinent but hasn’t fit in above. Additionally, this is an
organized place to put significant quotes or notes on events that may have
happened while pt. was being evaluated or in ER. Also these may pertain to
major medical issues if they could be related to mental health issues.
Example 1:
Pt. denies any h/o or current symptoms of psychosis/AVH. Denies any periods
suggestive of mania or hypomania (including grandiosity, decreased need for sleep,
and increased risk taking behavior – you may give direct pt quotes/examples at this point
if you wish). Denies any h/o trauma or PTSD symptoms.
Example 2:
Pt. additionally reports h/o physical abuse as child. Denies sexual abuse. Endorses
hyper-vigilance occurring most days, avoidance of situations which remind him of
childhood (“I never go by the school anymore”), nightmares occurring 1-2x week, and
exaggerated startle response. Denies flashbacks.
Example 3:
Of note, prior to arrival pt. reported to ER nursing staff that “I’ll say whatever I have
to for them to let me go.” During interview he was avoidant and asked several times if he
could leave the ER. He was difficult to discuss safety planning with, and pt’s brother
reports significant concern for his safety.
Example 4:
Of note, pt. has a h/o untreated hypothyroidism and reports he has not seen a primary
care doctor “in years.” He reports taking “a thyroid pill” at one point in the past but
cannot give further details.
This can be adjusted or changed based on both the presentation of the patient and the
style of the assessor. The paragraph separation helps me to organize the framework of
the information I want to present to the primary team and I think makes it easy for reader
to process and obtain the info. It also gives some flexibility if there appears to be 2 or 3
equal primary disorders, which often happens. Sometimes that can become difficult to
record the symptoms of each and difficult to tease apart exactly whats going on.
Obviously, a lot of the time all of this information can’t be obtained and this is sort of
a ideal scenario with family present. If something can’t be obtained in the middle of the
night then just say “can’t assess” but also put the reason. Each person needs to find their
own balance between recording a focused, organized history, but still being thorough and
hitting as much of the minimally necessary information as possible.
Only uses approved abbreviations
Overall Write-up is Legible and Intelligible Critical Factor
If a standardized form is used, ALL fill-ins and check boxes are addressed.
Indicate areas missed:
Assets and Strengths of patient are addressed
HPI provides sufficient content to understand the patient’s presentation
HPI/Plan are updated if admission delayed from initial write-up Critical Factor
Review of Systems is complete. Either “all negative” or if any are positive, all
others are each addressed individually as negative.
PE is complete and addresses what was examined and findings, including
pertinent negatives as indicated.
Vital signs and initial pertinent labs are documented on the H&P
Neuro exam documents at least -CN, Motor, Sensory, Strength, Gait, Reflexes,
Abnormal Movements-tics, tremors, posturing
Incomplete areas of history/physical exam are explained as to why
MSE is documented, can include MMSE when appropriate Critical Factor
Assessment/Formulation and Reason for admission is noted and explained
Clear provisional/primary diagnosis given (using DSM terminology) Critical Factor
Supporting diagnoses for consideration or rule-out are documented
Axis III includes related and/or active medical problems
Legal Status/Patient capacity for informed consent is addressed
Risk Assessment documented and appropriate plan for Monitoring and Risk
Reduction is initiated
Critical Factor
Medication plan is documented specifically-including strength, dose, route and
frequency- on the initial plan
Critical Factor
Patient participation in plan and consent for specific medication is noted (or
exceptions supported by documentation)
Documentation of other sources of information are noted (other service, family,
police, significant other, etc.)