History and Physical (H&P) Template

History and physical note: chief complaint, OLDCARTS HPI, histories, review of systems, exam by system, differential, plan

Y tếChuẩnhistory physicalCập nhật 20 thg 10, 2026

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Cách dùng: Use for admissions and new patient assessments. Start with the chief complaint and HPI, documenting pertinent negatives. Main pitfall: an assessment that repeats the history instead of synthesising it; this is a format, not clinical advice.

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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.

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

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

2. History of present illness

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

Element	Finding
Onset	[When and how it started: sudden or gradual]
Location	[Where; does it radiate]
Duration	[How long each episode lasts; constant or intermittent]
Character	[Quality, for example sharp, dull, pressure]
Aggravating factors	[What makes it worse]
Relieving factors	[What makes it better]
Timing	[Pattern, frequency, time of day]
Severity	[Score 0-10, effect on function]

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

3. Past medical and surgical history

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

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

5. Allergies

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

[Or state explicitly: no known drug allergies.]

6. Family history

Relative	Condition	Age at onset
[Relative]	[Condition]	[Age]
[Relative]	[Condition]	[Age]

7. Social history

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

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

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

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

11. Assessment

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

Problem list:

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

12. Differential diagnosis

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

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.

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