Vital Elements for H&P Writeups

Check off elements as you organize your write-up

Chief Complaint:

1-2 sentences which incorporate “in the patient’s words” the reason for coming in

History of Present Illness:

7 dimensions of cardinal symptom (quantity, quality, location, setting, chronology, aggravating/alleviating, associated manifestations) or PQRST system from POM

Chronological story begins at baseline state of health

Incorporates elements of PMH, FH, SH that are relevant to story (ex. risk factors for CAD)

Pertinent ROS +/- included

HPI reflects knowledge of differential diagnosis

Past Medical History:

Sufficient detail for diagnosis includes onset, complications, and therapy (ex AODM, insulin treated since 1995, no known nephropathy, eye changes)

Medications:

For each medication – dose, route, frequency

Includes over the counter, and prn (how much/frequently prn medicine is used)

Family History:

State of health of parents, siblings, children (all first degree relatives)

Extended family occurrence of CAD, CA, ETOH, DM, High Lipids, HTN, the disease/sx that pt. has

Social History:

Occupation, marital status

Tobacco, ETOH, substance abuse

Functional status, living situation (what will patient return to after visit/hospital stay)

Review of Systems:

All systems evaluated? (Constitutional, Skin, Heme/ Lymph, HEENT, Resp, CV, GI/ GU, Neuro/Psych, Endo, Musculoskeletal)?

Does not include PMH (ex. Heart murmur belongs in PMH, not ROS)

Adequate depth – (ex. In GI – no abdominal pain, bloating, nausea, melena, hematochezia, change in color, caliber, consistency or frequency of stool)

Physical Examination & Other Objective Data:

General description (can pick patient out of a line-up after reading it)

Vital signs including weight, height, orthostatic BP (when appropriate) and Pulse, Temp, RR

PEX includes the areas relevant to the chief complaint and areas identified as relevant through ROS

Includes skin examination

Includes lymph node survey (not limited to neck nodes only)

Includes thyroid examination

Respiratory includes more than “clear to auscultation”

Cardiovascular includes assessment of neck veins, and distal pulses

Abdominal examination includes measured liver span and rectal exam

Neurologic examination includes – mental status, cranial nerves, strength, sensation, cerebella function, reflexes

Includes lab data appropriate for HPI (identify significant abnormal values)

Lab data adequately reported (eg, includes intervals on EKG for syncope; UA fir renal failure, etc.)

Problem List:

Includes all active medical problems

Includes all abnormalities in laboratory findings and physical examination

Includes health maintenance/screening issues

Discussion/Plan:

Is specific to the patient, does not contain any summary of a textbook or review article

Adequate differential diagnosis reviewed for each problem when appropriate

Evaluation/diagnostic strategy proposed for each problem when appropriate

Management strategy discussed for each problem

Reflects an understanding of the pathophysiology of the patient’s illness

Format:

Legible

Avoids spelling or grammar errors

When citing sources - follow guidelines on Plagiarism handout in orientation folder (no direct cut and paste from anything is allowed)

Try to limit your references/primary sources to 5 per write-up