Medical Transcription: Overview of the History and Physical Examination
The admitting History and Physical Examination (known as an H&P) is the flagship of the “Big Four” reports that make up the core of medical transcription work. It’s almost as if you’re standing beside the healthcare provider as he meets the patient for the first time.
If you’re like most medical transcriptionists, it won’t be long before you start assessing symptoms, evaluating lab results, and diagnosing the patient yourself, before the official diagnoses are dictated.
An H&P is the first document added to a patient’s medical record. It’s the intake form used by hospitals, specialty clinics, and physicians seeing a patient for the first time. In an emergency situation, the surgeon needs that H&P in hand by the time a patient reaches the operating room (OR).
An H&P describes the patient’s initial symptoms and the history leading up to them, explores potential contributing factors, identifies potential diagnoses, and maps out a starting treatment plan. At its heart lies a detailed physical examination that methodically reviews all major body systems.
From its creation onward, the H&P is referred to by all healthcare providers with access to the chart that contains it. On repeat visits, additional reports are generated to document progress, treatments, operations, and so forth, but the initial H&P remains the anchor for the patient record.
The degree of detail included in a History and Physical Examination report is determined by the nature and complexity of a patient’s condition. The H&P for a patient with a straightforward, self-limiting problem can be quite brief. Reports on patients with multiple chronic conditions and/or acute illnesses or injuries can go into exhaustive detail.
An initial H&P typically includes the following major sections:
Chief Complaint: A succinct statement of the patient’s current primary problem(s)
History of Present Illness: A narrative history of precipitating events related to the patient’s current status
Past History: Details of the patient’s previous medical conditions and surgeries, family medical history, social history, and personal habits
Allergies: Whether the patient has any allergies to medications and what they are
Medications: List of the patient’s current medications
Review of Systems: An inventory of symptoms the patient is currently experiencing, as reported by the patient
Physical Examination: Objective physical and mental examination findings, often thorough and quite detailed
Diagnostic Studies: Results of laboratory tests, imaging, EKGs, and other diagnostic evaluations previously performed
Impression: Analyses of the patient’s condition and potential diagnoses
Plan: The next steps in the patient’s treatment
Most, but not all, of the examples you will see use heading and layout styles as recommended in The Book of Style for Medical Transcription, 3rd Edition, by AHDI. Some of the examples stray from The Book of Style in order to demonstrate other common layouts you’re likely to encounter, because report formatting varies to some degree between facilities.
Dictators don’t always word headings identically, though the meaning is still clear, and the examples reflect that as well. When transcribing, you should always format reports and headings as specified by the account you’re working on, regardless of what standards might otherwise apply.
The purpose of headings is to organize a report and make it easy to locate specific content. If a dictator starts a section that obviously belongs under a particular heading but doesn’t explicitly dictate the heading, it’s acceptable practice for the medical transcriptionist (MT) to insert it.