The comprehensive history and physical examination (H&P) is made up of the following nine major components: history of present illness (HPI), past medical history (PMH), family history, psychosocial, review of systems (ROS), physical examination, laboratory data, problem list, and treatment plan.
The HPI section addresses the current problem for which the patient is seeking care for and its chronological development up to the present time. The elements need to be documented are location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
The PMH section documents the patient’s past and current health. It is further subdivided to past medical history, surgical history or hospitalization, medications, …show more content…
Information regarding the patient’s occupation past/present, family situation, sexual orientation, religions, and cultural background assists clinicians treat the patient holistically and identify certain health risks. Documenting personal habits such as tobacco, alcohol, and drug use is important for identifying risk factors that could develop into certain medical conditions or complications. Information whether the patient is insured or uninsured guides clinician’s choice for healthcare treatment and prescriptions.
The ROS is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced (Sullivan, 2012). Both positive and negative symptoms are document in this section. A positive response would require the clinician to explore further. Fourteen systems reviewed are constitutional, eyes, ENT (ears, nose, mouth/throat), cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematology/lymphatic, and …show more content…
It is another way of documenting a patient encounter at the subsequent visit after a comprehensive H&P has been documented. Four components of a soap note are subjective, objective, assessment, and plan.
The Subjective section contains a complete description of the patient's description of symptoms as well as progress from the last encounter. This section contains the following sections from the comprehensive H&P: HPI, PMH, family history, psychosocial history, and ROS with all the pertinent positives and negatives. Occasionally, patient’s exact words are documented here in quotations to describe important information.
The Objective section contains the following data: vital signs (VS), an assessment of the patient, physical examination findings, and results from lab or diagnostic studies. Observed information is included here. Narrative and system headings formats are used for documenting the objective information portion of a SOAP note (Sullivan,
The HPI section addresses the current problem for which the patient is seeking care for and its chronological development up to the present time. The elements need to be documented are location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
The PMH section documents the patient’s past and current health. It is further subdivided to past medical history, surgical history or hospitalization, medications, …show more content…
Information regarding the patient’s occupation past/present, family situation, sexual orientation, religions, and cultural background assists clinicians treat the patient holistically and identify certain health risks. Documenting personal habits such as tobacco, alcohol, and drug use is important for identifying risk factors that could develop into certain medical conditions or complications. Information whether the patient is insured or uninsured guides clinician’s choice for healthcare treatment and prescriptions.
The ROS is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced (Sullivan, 2012). Both positive and negative symptoms are document in this section. A positive response would require the clinician to explore further. Fourteen systems reviewed are constitutional, eyes, ENT (ears, nose, mouth/throat), cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematology/lymphatic, and …show more content…
It is another way of documenting a patient encounter at the subsequent visit after a comprehensive H&P has been documented. Four components of a soap note are subjective, objective, assessment, and plan.
The Subjective section contains a complete description of the patient's description of symptoms as well as progress from the last encounter. This section contains the following sections from the comprehensive H&P: HPI, PMH, family history, psychosocial history, and ROS with all the pertinent positives and negatives. Occasionally, patient’s exact words are documented here in quotations to describe important information.
The Objective section contains the following data: vital signs (VS), an assessment of the patient, physical examination findings, and results from lab or diagnostic studies. Observed information is included here. Narrative and system headings formats are used for documenting the objective information portion of a SOAP note (Sullivan,