Chapter 2: Sections of an H&P Flashcards
What are the first 4 sections of an H&P?
Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH) and Past Surgical History (PHS) and Social History (SH)
What are the second 4 sections of an H&P?
Family History (FH), Allergies, Medications andImmunizations.
What are the third 4 sections of an H&P?
Review of Systems (ROS), Physical Examination (PE), Diagnosis (Dx) and Plan/Dispositon.
What is the Chief Complaint (CC) Section of an H&P?
Describes the symptoms or problem of the patient.
What is the Past Medical History (PMH) and Past Surgical History (PSH) Sections of an H&P?
Details of previous major illness, hospitalizations and surgeries.
What is the History of Present Illness (HPI) Section of an H&P?
Details of the illness or injury such as; location, severity, duration and associated signs or symptoms.
What is the Social History (SH) Section of an H&P?
Review of diet, exercise, education, occupation, use of drugs, sleep habits, living situation, family structure and travel history.
What is the Family History (FH) Section of an H&P?
Review on hereditary diseases, if the patient was adopted, provider notes it in the medical record.
What is the Allergies Section of an H&P?
Any allergies that the patient has on drugs, food, latex, etc.
What is the Medications Section of an H&P?
A list of medications and prescriptions that the patient takes and the dosages.
What is the Immunization Section of an H&P?
Documentation of patient’s up-to-date (UTD) Immunizations.
What is the Review of Systems (ROS) Section of an H&P?
The review of systems of each body system.
What is the Physical Examination (PE) Section of an H&P?
Examination of the patient for any signs or symptoms of a medical condition.
Diagnosis (Dx) Section of an H&P sometimes is called?
Impression or Assessment.
What is the Plan/Disposition Section of an H&P?
Treatment plan for the patient, can refer to specialists and other instructors.
