Understanding the History and Physical
The History and Physical (H&P) is the cornerstone of medical documentation, providing a comprehensive snapshot of a patient's health status at the time of hospital admission or significant medical encounter. A well-documented H&P guides clinical decision-making, supports billing, and meets regulatory requirements from CMS and Joint Commission.
Whether you're a medical student preparing for clinical rotations, a resident honing your documentation skills, or an attending physician seeking efficient templates, this guide provides everything you need to create complete, compliant H&P documentation in 2026.
Regulatory Requirement
Per 42 CFR 482.24 (CMS Conditions of Participation), an H&P must be completed no more than 30 days before or 24 hours after hospital admission, and must be placed in the medical record within 24 hours of admission—but always before surgery or anesthesia.
H&P Timing and Update Requirements
Understanding when an H&P is valid and when updates are required is essential for compliance and avoiding denied claims or survey deficiencies.
| Scenario | Requirement | Timing |
|---|---|---|
| New H&P at admission | Complete H&P required | Within 24 hours of admission |
| H&P done within 30 days prior | Update note required | Within 24 hours of arrival, before surgery |
| H&P done >30 days prior | New complete H&P required | Within 24 hours of admission |
| Continuous hospitalization | Original H&P valid for entire stay | Updates via progress notes |
| Readmission after discharge | New H&P or valid prior H&P + update | Within 24 hours of readmission |
Important: Surgical Patients
For any patient undergoing surgery or a procedure requiring anesthesia, the H&P (or update) must be completed and in the chart before the procedure begins. This is a non-negotiable patient safety requirement.
Comprehensive H&P Template
Use this template as a framework for complete H&P documentation. Customize based on your institution's requirements and the patient's specific clinical situation.
Patient Information
Patient Name
___________________________
MRN
___________________________
DOB / Age
___________________________
Date of Admission
___________________________
Date of H&P
___________________________
Attending Physician
___________________________
Chief Complaint (CC)
The primary reason for the patient's visit, in their own words when possible.
"[Patient's chief complaint in quotes]"
History of Present Illness (HPI)
Detailed narrative of the patient's current illness. Use OLDCARTS mnemonic for comprehensive documentation.
OLDCARTS Mnemonic
[Patient] is a [age]-year-old [gender] with a past medical history significant for [relevant PMH] who presents with [CC] for [duration].
The patient reports that symptoms began [onset] and are described as [characteristics]. Symptoms are [better/worse] with [factors]. The patient has tried [treatments] with [results]. Current severity is [X/10]. Associated symptoms include [list]. The patient denies [pertinent negatives].
Past Medical History (PMH)
Medical Conditions
- 1. _______________________
- 2. _______________________
- 3. _______________________
- 4. _______________________
- 5. _______________________
Past Surgical History (PSH)
- 1. ______________ (year: ____)
- 2. ______________ (year: ____)
- 3. ______________ (year: ____)
Medications & Allergies
Current Medications
(Include dose, route, frequency)
- 1. _______________________
- 2. _______________________
- 3. _______________________
- 4. _______________________
- 5. _______________________
Allergies
(Include reaction type)
- 1. ___________ → ___________
- 2. ___________ → ___________
□ NKDA (No Known Drug Allergies)
Social & Family History
Social History
Tobacco: _________________________
Alcohol: _________________________
Drugs: _________________________
Occupation: _____________________
Living situation: __________________
Exercise: _______________________
Diet: ___________________________
Family History
Father: _________________________
Mother: ________________________
Siblings: _______________________
CAD: □ Yes □ No
Diabetes: □ Yes □ No
Cancer: □ Yes □ No Type: ________
HTN: □ Yes □ No
Review of Systems (ROS)
Document positive and pertinent negative findings for each system.
Constitutional
□ Fever □ Chills □ Fatigue
□ Weight loss □ Weight gain
□ Night sweats
HEENT
□ Headache □ Vision changes
□ Hearing loss □ Sore throat
□ Nasal congestion
Cardiovascular
□ Chest pain □ Palpitations
□ Edema □ Orthopnea
□ PND □ Claudication
Respiratory
□ Cough □ SOB □ Wheezing
□ Hemoptysis □ Sputum
□ DOE
GI
□ Nausea □ Vomiting □ Diarrhea
□ Constipation □ Abdominal pain
□ Blood in stool
GU
□ Dysuria □ Frequency
□ Urgency □ Hematuria
□ Incontinence
Musculoskeletal
□ Joint pain □ Muscle pain
□ Weakness □ Stiffness
□ Back pain
Neurological
□ Numbness □ Tingling
□ Weakness □ Dizziness
□ Seizures □ Syncope
Psychiatric
□ Depression □ Anxiety
□ Sleep disturbance
□ SI/HI
All other systems reviewed and negative unless noted above.
Physical Examination
Vital Signs
General
Alert, oriented, no acute distress. Well-developed, well-nourished. Appropriate affect.
HEENT
Normocephalic, atraumatic. PERRLA, EOMI. TMs clear. Oropharynx clear, moist mucous membranes.
Neck
Supple, no lymphadenopathy, no thyromegaly, no JVD.
Cardiovascular *
RRR, normal S1/S2, no murmurs/rubs/gallops. No peripheral edema. 2+ pulses bilaterally.
Respiratory *
Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. No respiratory distress.
Abdomen
Soft, non-tender, non-distended. Normoactive bowel sounds. No hepatosplenomegaly.
Extremities
No clubbing, cyanosis, or edema. Full ROM. 5/5 strength throughout.
Neurological
A&Ox3. CN II-XII intact. Sensation intact. DTRs 2+ throughout. Gait normal.
Skin
Warm, dry, intact. No rashes, lesions, or wounds.
Psychiatric
Appropriate mood and affect. Normal speech. Thought process linear. No SI/HI.
* Heart and Lungs are minimum required systems per CMS/Joint Commission
Assessment & Plan
Summary Statement
[Age]-year-old [gender] with PMH of [conditions] presenting with [CC] most likely secondary to [diagnosis].
#1. [Primary Diagnosis]
- • Workup: [labs, imaging, studies]
- • Treatment: [medications, interventions]
- • Consults: [if applicable]
#2. [Secondary Diagnosis]
- • Continue current management
- • Monitor for [complications]
#3. [Additional Problem]
- • Plan details here
Disposition
□ Admit to [unit/floor] □ Observation □ Discharge
Code Status: □ Full Code □ DNR □ DNI □ DNR/DNI □ Comfort Care
Authentication
Performed by:
_________________________________
Print Name / Credentials
Signature:
_________________________________
Signature / Date / Time
Attending Attestation (if applicable):
"I have reviewed the H&P performed by [name] and agree with the documented findings. I was present during key portions of the evaluation and personally examined the patient."
H&P Update Template
When the original H&P was completed within 30 days of admission, use this update template to document any changes in the patient's condition.
H&P Update Note
Original H&P Date: _______________
Update Date/Time: _______________
Reason for Admission: _______________
Interval History:
Since the H&P dated [date], the patient reports: [any new symptoms, changes in condition, or if no changes: "no significant changes"]
Medication Changes: [list any changes or "no changes"]
New Allergies: [list or "none"]
Focused Physical Exam:
VS: [current vitals]
Pertinent findings: [any changes from original H&P]
Assessment: Patient condition is [stable/improved/worsened]. Ready to proceed with planned [surgery/procedure].
Signature: _______________ Date/Time: _______________
Frequently Asked Questions
What is a History and Physical (H&P)?
A History and Physical (H&P) is a comprehensive medical document that records a patient's complete health history and physical examination findings. It serves as the foundation for medical decision-making during hospital admissions, surgeries, and significant medical procedures. The H&P includes chief complaint, history of present illness (HPI), past medical/surgical history, medications, allergies, social/family history, review of systems (ROS), physical exam findings, assessment, and plan.
What are the CMS requirements for H&P documentation?
According to CMS Conditions of Participation (42 CFR 482.24), an H&P must be completed and documented no more than 30 days before or 24 hours after hospital admission, and must be in the medical record within 24 hours of admission. If the H&P was done within 30 days prior to admission, an update documenting any changes must be completed within 24 hours after arrival but before surgery or anesthesia.
Who can perform and document an H&P?
An H&P must be performed by a licensed practitioner who is credentialed and privileged by the hospital's medical staff to perform H&Ps. This typically includes physicians (MD/DO), nurse practitioners (NP), and physician assistants (PA). Medical students may participate but require supervision and co-signature by a credentialed practitioner.
What is the difference between a comprehensive and focused H&P?
A comprehensive H&P includes a complete history and full multi-system physical examination, typically required for hospital admissions and new patient evaluations. A focused H&P concentrates on a specific problem or body system, appropriate for follow-up visits or when addressing a single issue. Hospital admissions require a comprehensive H&P.
When is an H&P update required?
An H&P update is required when the original H&P was completed within 30 days prior to admission. The update must be done within 24 hours after the patient arrives for admission (but before surgery/anesthesia) and must document any changes in the patient's condition since the original H&P. If the H&P is more than 30 days old, a new complete H&P is required.
What are the required elements of a complete H&P?
Per CMS and Joint Commission, required elements include: chief complaint, history of present illness, relevant past medical history appropriate to patient's age, current medications, allergies, review of systems (minimum heart and lungs), complete physical examination, assessment/conclusion/impression, and plan of care.
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