Medical Transcription: Sections of the History of Physical Examination Report
Here are all the sections that might be included in a History and Physical Examination Report that you will come across as a medical transcriptionist, and some examples of how they are commonly formatted.
The first major section of an H&P, Chief Complaint, is a very concise answer to the question “Why is the patient seeking medical care today?” It may be a few words or at most a few sentences.
Chief Complaint section is sometimes called Presenting Problem or Presenting Complaint. When stated using the patient’s own words, it should be enclosed in quotes. Even if it’s only a partial phrase, place a period at the end.
Here are a couple examples:
“I feel dizzy.”
Status post motor vehicle accident.
History of present illness
History of Present Illness (HPI) fleshes out the chief complaint by discussing the patient’s problem in detail. The dictator also may title this section History of Presenting Problem, History, or HPI.
The HPI is written in narrative format. It typically begins with a brief description of the patient (for example, “a 61-year-old Caucasian female”) and then discusses symptoms and events leading up to and surrounding the chief complaint. The information may come from the patient, the patient’s relatives, and/or previous medical records.
Here’s an example:
HISTORY OF PRESENT ILLNESS
This 82-year-old African-American female patient has had progressive weakness, which was worse yesterday and prompted her to go to the emergency room. She was found to have an abnormal chest X-ray and admitted for community-acquired pneumonia. She did have cough and audible wheezing but no chest pain or shortness of breath.
Review of past history
The Review of Past History section describes previous illnesses, operations, injuries, and treatments not necessarily related to the present illness. It also reviews family medical history and the patient’s lifestyle, all factors that can play into the patient’s current state of health.
Depending on the dictator and facility preferences, the review of past history may be grouped into one paragraph under the single heading Past History or broken out into individual major headings. The paragraph format looks like this (and the individual headings are covered in the following sections):
The patient had a CVA involving the right side with left-sided weakness about 15 years ago and has completely recovered. Since then, she has been active and walks daily. No past surgeries. Family history noncontributory.
The Allergies heading is always included in an H&P. Any allergies are typed in capital letters to make them stand out. Allergies to Medication may be dictated as an alternate heading. If NKDA, an acronym for “no known drug allergies,” is dictated, it should be spelled out.
ALLERGIES: No known drug allergies.
ALLERGIES: ALLERGIC TO CODEINE AND DEMEROL.
This section details medications and over-the-counter supplements the patient currently takes. It includes vitamins and herbal supplements, as well as prescribed drugs. In a hospital H&P, this is often referred to as Medications on Admission. This section may be dictated as a numbered list or strung together in a paragraph. Dosage information may or may not be included; it’s often left out on admission because the patient may not know it.
MEDICATIONS ON ADMISSION: Aspirin, Procardia, and multivitamins.
1. Celexa 20 mg p.o. in the morning for depression.
2. Ativan 0.5 mg for anxiety every 6 hours as needed.
3. Vitamin D daily, dosage unknown.
Review of systems
The Review of Systems (ROS) is a systematic inventory of potential symptoms the patient may be experiencing, organized by body system. Alternative headings include Systemic Review and Functional Inventory. It also may be referred to as a 12-Point Review of Systems. As with the Past History, much or all of this section may originate from a form the patient fills out in the waiting room.
The ROS may be dictated in paragraph form with no headings or divided into subtopics. Although the subtopic ordering generally starts with the patient’s head and proceeds downward, the exact division and arrangement won’t always be the same.
If there is no meaningful information for a particular body system or even the entire inventory, the dictator may say “noncontributory” or something similar or even skip this section entirely. The use of well-known abbreviations in subtopic headings is permissible and common.
Here’s an ROS organized by subtopic:
REVIEW OF SYSTEMS
CONSTITUTIONAL: No history of fever, rigors, or chills.
ENT: No blurred vision or double vision. No headache.
CV: As above.
RESPIRATORY: No shortness of breath, PND, or orthopnea.
GI: No abdominal pain, hematemesis, or melena.
Here’s an ROS in paragraph form:
REVIEW OF SYSTEMS: The patient does not complain of any headache, vision changes, hearing changes, constitutional symptoms, shortness of breath, chest pain, bowel or bladder disturbances, joint or muscle aches, or depression or anxiety symptoms.
REVIEW OF SYSTEMS: Otherwise negative except as in HPI.
The Physical Examination (PE) is an objective assessment of the patient’s condition. The examiner observes, pokes, and prods the patient and records the results here. In some report types, a brief, focused exam may be conducted, but an exam done as part of an H&P typically assesses the patient from head to toe, one body system at a time.
Although a PE can be dictated as a narrative paragraph, in an H&P it’s more common for each body area to be listed individually.
Diagnostic Studies includes laboratory test results and findings from imaging studies such as X-rays, CAT scans, and MRIs. EKGs and EEGs are reported in this section, too. Instead of lumping these together under Diagnostic Studies, dictators may break them into separate headings, such as Laboratory Data and Imaging.
Conversely, a dictator may dictate the heading Laboratory Data instead of Diagnostic Studies and then include findings from MRIs, EKGs, and other diagnostic procedures, which are technically not lab results. In this case, the MT may modify the headings for clarity, typically by inserting an additional heading immediately below the Laboratory Data section.
White count 9, hemoglobin 14.8, platelet count 322. Sodium 131, potassium 4.3, chloride 101. BUN 14, creatinine 1.3.
Head CT is currently pending. Chest x-ray unremarkable.
Assessment and plan
Alternative titles for this section include Impression, Diagnosis, and Conclusion. Because an H&P is conducted at the time of a new patient encounter, there often isn’t enough data to reach a firm diagnosis yet; the patient’s condition is still being assessed and test results may be pending.
Therefore, this section often lists provisional diagnoses or itemizes symptoms and conditions that clearly exist and need to be further investigated rather than final diagnoses. Sometimes the assessment and plan will be dictated as distinct sections, each with its own heading.
It’s pretty rare for a patient to have a single condition, so items in this section are typically listed vertically as a numbered list. If there’s only one item, don’t number it, even if the dictator does. Place a period at the end of each item listed, even if it’s only one word or a partial phrase.
All abbreviations or acronyms dictated under this heading should be expanded, even if previously defined in the report, unless
The abbreviation has more than one possible expansion and you’re not crystal clear on which one it refers to.
It refers to a disease entity that’s better known and recognized by the abbreviation than the expanded name, such as AIDS or HIV.
It refers to a non-disease entity such as a lab test (for example, BUN), unit of measure (for example, cm), or medical device (for example, BiPAP mask).
An assessment and plan dictated as a unit looks like this:
ASSESSMENT AND PLAN
1. Chest pain. Cardiac enzymes are negative x2. We will continue aspirin and statin. We will obtain adenosine Myoview stress test today. If negative, okay to discharge to home.
2. Hypertension. Blood pressure is stable. Continue diuretic.
3. History of gastroesophageal reflux disease (GERD). Continue omeprazole.
When dictated separately, the format will be similar to this:
1. Urinary dysuria.
2. Left flank pain
Rocephin 1g IM was given. She is to call her primary care physician tomorrow morning in case a second dose is needed. If not, she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days.