Chief Complaint (HPI)

Introduction and Importance

A comprehensive history and physical (H&P) is a critical first step in the assessment of any patient. They often provide much more information than most broad examination and testing approaches do since the information is coming directly from the patient. Thorough H&P’s can help providers identify possible disease and illness helping aide in the diagnostic process and our frequently used as the foundation of medical management throughout an entire course of treatment with a provider.

Identification

This component is the beginning and general introduction and identification of the encountered patient. General identifiers are used such as the patients name, date of birth, race, age, and gender. Also, important

It is important to document the reason for seeking care even if there is no specific complaint such as presenting for their initial or annual wellness visit. The (CC) is best documented in the patient’s exact words by using quotation marks.

History of the Present Illness (HPI) or History of the Chief Complaint (HCC)

The (HPI) is a description of the patient’s chief complaint from the time any first signs and symptoms began to the current point in time. It is important to document elements including location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. There are many different mnemonics that have been created to remember these elements such as PQRST and LOCATES.

Past Medical History (PMH) The past medical history component identifies any past diagnosis the patient may have received along with possible hospitalizations or traumas. This also identifies whether diagnoses are still active or inactive. It is important to also note in this section any allergies to both food or medication, the patient’s immunization status and well checkup status, as well as current meds the patient may be

Things such as employment, relationship status, living environment, financial status, supports systems and so forth. Another very important part to the psychosocial component is identifying the patients use of any illicit drugs, alcohol, tobacco, excessive prescription medication or even over the counter medication.

Review of Systems (ROS)

The ROS is used to document any symptoms the patient is currently experiencing or has experienced generally within the last year regarding each specific body system (Constitutional, Eyes, Ears, nose, & throat (ENT), Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Integumentary, Neuro, Psychiatric, Endocrine, Hematologic/lymphatic, Allergic/immune) (Sullivan, 2012). Positive or negative results are documented with further description and documentation of positive findings warranted.

Physical Examination

The physical exam is a head to toe assessment generally documenting the presence or absence of symptoms along with the patient’s appearance regarding; General, Vital signs, Skin, Head, Eyes, Ears, Nose, Mouth/Throat (HEENT), Neck, Respiratory, Cardiovascular, Abdomen, Rectal, Genitalia/ Pelvic, Musculoskeletal, and Neurological (Sullivan,