Which items are typically included in History and Physical?

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Multiple Choice

Which items are typically included in History and Physical?

The item that belongs in a History and Physical is the present and past history. The History and Physical is meant to capture who the patient is and what brings them in, along with their broader health background. This includes the current symptoms and the course of the present illness (present history), as well as prior illnesses, surgeries, medications, allergies, and family/social history (past history). These elements give the clinician a full context to understand the new problem and plan care. Discharge summaries are written after a hospitalization to summarize what happened and the outcome, not at the time of the initial assessment. Surgical records and imaging studies are separate parts of the chart: surgical records document past procedures, and imaging studies are test results reviewed or referenced as part of the assessment, not the primary content of the History and Physical.

The item that belongs in a History and Physical is the present and past history. The History and Physical is meant to capture who the patient is and what brings them in, along with their broader health background. This includes the current symptoms and the course of the present illness (present history), as well as prior illnesses, surgeries, medications, allergies, and family/social history (past history). These elements give the clinician a full context to understand the new problem and plan care.

Discharge summaries are written after a hospitalization to summarize what happened and the outcome, not at the time of the initial assessment. Surgical records and imaging studies are separate parts of the chart: surgical records document past procedures, and imaging studies are test results reviewed or referenced as part of the assessment, not the primary content of the History and Physical.

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