Writing a History and Physical

Jeffrey L. Greenwald (Author)

9781560536024, Elsevier Health Sciences

Hardback, published 3 June 2003

80 pages
15.2 x 10.2 x 0.7 cm, 0.07 kg

Central to providing excellent patient care is excellent communication, for which a well-written History and Physical is crucial. This book is a step-by-step guide to help medical students, nurse practitioners, physician assistants, etc. write a comprehensive, clear, and useful History and Physical. Writing an effective History and Physical is as much an art as science, and this handy guide provides a roadmap for organizing facts in a logical and well-constructed fashion. The text also presents an abridged version for quick reference and a valuable section on how to write daily progress notes.

• The author's tips pearls, and advice help the reader navigate the principles and goals of the History and Physical
• Contains more explanations, tips and advice than existing books for what to include and why
• Memorable good and bad examples reinforce themes in the text

1. Source
2. Chief Complaint (CC)
3. History of the Present Illness (HPI)
4. Past Medical History (PMH)
5. Medications (Meds)
6. Allergies (All)
7. Family History (FHx)
8. Social History (SHx)
9. Review of Systems (ROS)
10. Physical Exam (PE)
11. Laboratories/Data
12. Assessment/Impression/Summary
13. The Plan
14. Problem List
15. Organ System Approach
16. Writing a History and Physical: The Abridged Guide
17. Writing a Daily Progress

Subject Areas: Clinical & internal medicine [MJ]