# History and Physical: [Patient ID placeholder]

> History and physical examination (H&P) note for an admission or a new
> patient assessment: chief complaint, history of present illness using
> the OLDCARTS mnemonic, past history, medications, allergies, family and
> social history, review of systems, examination by system, assessment,
> differential diagnosis and plan. Based on common clinical documentation
> practice. This is a documentation format, not clinical advice. Use
> placeholders only in this template, and follow local privacy law (for
> example HIPAA or GDPR) and your institution's documentation policy when
> completing a real record.

<!--
Guidance: How to use this template
- Record the patient's own words for the chief complaint, then build the
  history of present illness around it.
- Document pertinent negatives: findings you looked for and did not find
  are as important as positive findings for the differential.
- The assessment should be a synthesis, not a repeat of the history. Link
  each plan item to a problem.
- Delete systems you did not examine rather than writing "normal" for
  them; only document what was done.
-->

| Field | Value |
|---|---|
| Patient name | [Patient name] |
| Patient identifier | [MRN / health number] |
| Date of birth / age | [YYYY-MM-DD] / [age] |
| Date and time of assessment | YYYY-MM-DD HH:MM |
| Setting | [Admission / clinic / emergency department] |
| Source of history | [Patient / family member / records / interpreter used] |
| Reliability | [Reliable / limited, with reason] |
| Clinician | [Name, role] |

## 1. Chief complaint

<!-- Guidance: One line, ideally in the patient's words, with duration. -->

"[Patient's words]" for [duration]. *Example:* "Chest tightness when I
walk uphill" for 3 weeks.

## 2. History of present illness

<!-- Guidance: Tell the story chronologically. OLDCARTS is a prompt, not a form to fill mechanically; cover each element that applies. Include relevant risk factors and pertinent negatives. -->

[Narrative paragraph: age, relevant background and the story of the
current problem in chronological order.]

| Element | Finding |
|---|---|
| **O**nset | [When and how it started: sudden or gradual] |
| **L**ocation | [Where; does it radiate] |
| **D**uration | [How long each episode lasts; constant or intermittent] |
| **C**haracter | [Quality, for example sharp, dull, pressure] |
| **A**ggravating factors | [What makes it worse] |
| **R**elieving factors | [What makes it better] |
| **T**iming | [Pattern, frequency, time of day] |
| **S**everity | [Score 0-10, effect on function] |

Pertinent positives: [list]. Pertinent negatives: [list].

## 3. Past medical and surgical history

<!-- Guidance: Include dates and current status. Note conditions relevant to the present illness first. -->

| Condition or operation | Year | Status / details |
|---|---|---|
| [Condition] | [YYYY] | [Controlled / complications] |
| [Operation] | [YYYY] | [Outcome] |
| [Hospitalisation] | [YYYY] | [Reason] |

Obstetric history, if relevant: [details]. Immunisations: [status].

## 4. Medications

<!-- Guidance: Include prescription, over-the-counter, herbal and recreational substances. Check adherence and recent changes. -->

| Medication | Dose, route, frequency | Indication | Adherence / last dose |
|---|---|---|---|
| [Medication] | [Dose, route, frequency] | [Indication] | [Adherence] |
| [Medication] | [Dose, route, frequency] | [Indication] | [Adherence] |

## 5. Allergies

<!-- Guidance: Record the reaction, not just the substance. Distinguish allergy from intolerance. -->

| Substance | Reaction | Type |
|---|---|---|
| [Substance] | [Reaction] | [Allergy / intolerance] |

[Or state explicitly: no known drug allergies.]

## 6. Family history

<!-- Guidance: Focus on first-degree relatives and conditions relevant to the presenting problem. -->

| Relative | Condition | Age at onset |
|---|---|---|
| [Relative] | [Condition] | [Age] |
| [Relative] | [Condition] | [Age] |

## 7. Social history

<!-- Guidance: Cover what affects diagnosis, risk and discharge planning: function, support, occupation, substances. Ask sensitively and record only what is clinically relevant. -->

| Domain | Details |
|---|---|
| Living situation and support | [Lives alone / with family; carer] |
| Occupation and exposures | [Occupation; relevant exposures] |
| Tobacco | [Never / former / current; pack-years] |
| Alcohol | [Units per week] |
| Other substances | [Type, route, frequency] |
| Functional status | [Independent / needs help with activities] |
| Travel | [Recent travel, if relevant] |

## 8. Review of systems

<!-- Guidance: Record positives and pertinent negatives by system. Do not repeat what is already in the HPI. -->

| System | Findings |
|---|---|
| General | [Fever, weight change, fatigue] |
| Cardiovascular | [Chest pain, palpitations, oedema] |
| Respiratory | [Cough, breathlessness, wheeze] |
| Gastrointestinal | [Appetite, nausea, bowel change] |
| Genitourinary | [Urinary symptoms] |
| Musculoskeletal | [Joint pain, stiffness] |
| Neurological | [Headache, weakness, sensory change] |
| Psychiatric | [Mood, sleep] |
| Skin | [Rash, lesions] |
| Endocrine | [Thirst, heat or cold intolerance] |

## 9. Physical examination

<!-- Guidance: Start with general appearance and vital signs. Document by system, with positive and pertinent negative findings. -->

| Vital sign | Value |
|---|---|
| Temperature | [°C] |
| Heart rate | [bpm] |
| Blood pressure | [mmHg] |
| Respiratory rate | [breaths/min] |
| Oxygen saturation | [% on room air / oxygen] |
| Weight / height / BMI | [kg / cm / kg/m²] |

| System | Findings |
|---|---|
| General appearance | [Alert, distress level] |
| Head, eyes, ears, nose, throat | [Findings] |
| Neck | [Findings] |
| Cardiovascular | [Heart sounds, pulses, oedema] |
| Respiratory | [Inspection, percussion, auscultation] |
| Abdomen | [Inspection, palpation, bowel sounds] |
| Musculoskeletal | [Findings] |
| Neurological | [Mental status, cranial nerves, motor, sensory, reflexes, gait] |
| Skin | [Findings] |
| Psychiatric | [Mood, affect, thought content] |

## 10. Results available at assessment

<!-- Guidance: Include only results available at the time of writing, with dates. -->

| Test | Result | Date |
|---|---|---|
| [Test] | [Result] | YYYY-MM-DD |
| [Test] | [Result] | YYYY-MM-DD |

## 11. Assessment

<!-- Guidance: A short synthesis: who the patient is, the key findings and your leading impression. Then list active problems. -->

[One-paragraph summary: age, relevant background, presenting problem, key
positive and negative findings and the working diagnosis.]

Problem list:

1. [Problem 1, working diagnosis]
2. [Problem 2]
3. [Problem 3]

## 12. Differential diagnosis

<!-- Guidance: Rank by likelihood and seriousness. Give the evidence for and against each, and how you will confirm or exclude it. -->

| Rank | Diagnosis | Supporting findings | Against | Next step to confirm or exclude |
|---|---|---|---|---|
| 1 | [Most likely diagnosis] | [Findings] | [Findings] | [Test] |
| 2 | [Alternative] | [Findings] | [Findings] | [Test] |
| 3 | [Must-not-miss diagnosis] | [Findings] | [Findings] | [Test] |

## 13. Plan

<!-- Guidance: Organise by problem. For each, list investigations, treatment, monitoring and patient communication. Note escalation decisions. -->

| Problem | Investigations | Treatment | Monitoring | Communication |
|---|---|---|---|---|
| [Problem 1] | [Tests] | [Treatment] | [Observations, frequency] | [Discussed with patient] |
| [Problem 2] | [Tests] | [Treatment] | [Monitoring] | [Communication] |

Escalation and resuscitation status: [as discussed and documented per
local policy]. Disposition: [admit to / discharge with / observe].

Signature: [Name, role, registration number], YYYY-MM-DD HH:MM.

## Standard and licence note

Based on common clinical documentation practice for the history and
physical examination, including the widely taught OLDCARTS mnemonic for
symptom history. This is a documentation format, not clinical advice;
follow local privacy law and your institution's documentation policy.
Template licence: MIT.