HOW TO WRITE A HISTORY AND PHYSICAL (H&P)

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🌱 來自: Practical Skills for Learners

HOW TO WRITE A HISTORY AND PHYSICAL (H&P)🚧 施工中

HOW TO WRITE A HISTORY AND PHYSICAL (H&P)

Early in training, writing an H&P can sometimes seem overwhelming. Developing a consistent approach, particularly to the HPI, can help reduce the time required for documentation and be useful for keeping a mental checklist during the patient encounter to make sure you’re collecting all the necessary information.

TABLE A1.1 • Aspects of an Admission Note for Internal Medicine (“H&P”)

Now, let’s break down each section and provide some specific guidance:

Chief Complaint and History of Present Illness (HPI)

Additional History

Physical Exam, Labs, and Other Data

The Assessment and Plan (A&P)