History and Physical Exam (H&P)
This is the initial note. Here’s a really comprehensive list.
| Section | Stands for | What goes in it |
|---|---|---|
| CC | Chief Complaint | Why they’re here, ideally in the patient’s own words |
| HPI | History of Present Illness | The story of the CC: onset, duration, severity, what helps/worsens |
| PMHx | Past Medical History | Chronic conditions, past hospitalizations |
| PSHx | Past Surgical History | Past surgeries and when |
| All | Allergies | Drug/food allergies and the reaction |
| Meds | Medications | Current meds, doses, frequency |
| FamHx | Family History | Conditions that run in the family |
| SocHx | Social History | Home, school/work, smoking/alcohol/drugs, stressors |
| ROS | Review of Systems | Head-to-toe checklist of symptoms, by organ system |
| PE | Physical Exam | Starts with vitals, then exam by system |
| Data | Data | Labs, imaging, other studies, with trends |
| A/P | Assessment and Plan | What you think is going on and what you’ll do about it |
Follow-up Subjective Objective Assessment Plan (SOAP) Note
The H&P is done once, at admission or a first visit. After that, each day (or visit) gets a shorter progress note in SOAP format. It’s also how residents present a patient to the attending.
| Part | What goes in it | |
|---|---|---|
| S | Subjective | What the patient (or family, or nurse) tells you. How they feel, new symptoms, what happened overnight. The story. |
| O | Objective | What you measure today. Vitals, physical exam, I/Os (intake and output), labs, imaging. No story, just data. |
| A | Assessment | Your interpretation. Usually a one-liner (who, why they’re here, how they’re doing) then the problem list. |
| P | Plan | What you’ll do about each problem: tests, meds, consults, disposition (e.g. discharge). |
A and P are often written together, problem by problem:
A/P: 7 y/o M w/ community-acquired pneumonia, hospital day 2, improving.
- Pneumonia: Afebrile x 24h, O₂ weaned to room air. Continue amoxicillin, day 2 of 7.
- Hydration: Tolerating PO. Stop IV fluids.
- Dispo: Likely discharge tomorrow if stays afebrile.
H&P vs SOAP
The H&P is the full story, written once. SOAP notes are daily updates that assume you’ve read the H&P, so they skip PMHx, FamHx, SocHx, etc. unless something changed.