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The document specifies what to include in the introductory chief complaint statement, source and reliability, primary clinicians, and a narrative HPI with chronological flow, symptom characterization, key positives and negatives, and relevant context from PMH/SH/FH/ROS. It also details expected documentation for past medical history, medications with dosing and allergies, and social history plus functional status and substance use.","Guidelines for the History and Physical Exam Write-up\nDepartment of Medicine\nBoston University School of Medicine\nRevised January 28, 2008\nIntroductory Statement with Chief Complaint:  is a brief statement explaining the reason the patient presented to the hospital or ambulatory setting (if appropriate).  It includes the patient’s age, gender, most pertinent past medical history and major symptoms(s) and duration.  Whenever possible, this statement should identify the significant issue from the patient’s perspective, and include the patient’s words if the patient accurately represents the reason for the presentation.  This statement should not contain a litany of nonpertinent PMH.\nFor example, “Mr. G is a 54 year-old man with a history of coronary heart disease who presents with 3 hours of crushing substernal chest pressure.”\nClarification may be needed in certain circumstances when the patient may be feeling well but have abnormal lab values or unable to accurately indicate symptoms or reason for admission.  For example, “Ms. S is an 82 year old woman with a history of dementia who is admitted for hyperkalemia and acute renal failure.”\nConcise statement that describes the patient’s age, gender, most pertinent past medical history and the major reason(s) for presentation and its duration.\n2) Source and Reliability:\nProvides the major sources(s) of information used in the write-up, whether an interpreter was used, and a comment about the reliability of the information.  The sources(s) may include one or more of the following: the patient, family member or partner, witness to the key event and/or medical records.\n3) Primary Physician(s):  Identifies the clinicians most involved with the patient’s care.  It serves a reminder to the inpatient team to both respect and support those relationships and to communicate with these clinicians who have valuable clinical information and insights.\nIdentifies the clinician(s) primarily involved in this patient’s care.\n4) History of Present Illness:  The HPI is the central component of this history and should:\nProvides a chronological description of the patient’s story, usually addressing the story of the symptoms first.  (manifestations/symptoms of illness, interventions, patient interpretations).\nIncludes pertinent context from the “rest of the history” (PMH, SH, Habits, FH, ROS).  All historical information that is key to understanding the differential diagnosis of the primary problem(s) should be included here. The HPI should be written in prose with full sentences and be a narrative that builds an argument for the reason the patient was admitted.\nHas a starting point (i.e. “the patient was in her usual state of health until 5 days prior to admission.).\nHas appropriate flow, continuity, sequence, and chronologic order.\nProvides a chronological description of symptoms, interventions (by the patients, MD, others) and pertinent patient interpretations of the symptoms.   This may include the ER/MICU course or prior therapeutic treatments e.g. chemotherapy.\nContains an appropriate characterization of key symptoms—onset, quality, quantity, location, setting, chronology (including whether the symptom is constant of intermittent, progressive or improving),modifying factors, severity including impact on function and associated symptoms.\nIncorporates pertinent (needed to understand the differential diagnosis) elements of past medical history, family history, social history, substance use and review of symptoms. (i.e. for chest pain: CHD risk factors are included at the end of the HPI; DVT/PE risk factors included if pertinent; if COPD/asthma is being considered, indicate use of steroids, prior hospitalizations, prior intubations and recent PFTS included in HPI.).\nIncludes pertinent positive and negatives which demonstrate the presenter’s thought process about the differential diagnosis.\nPlaces results of tests performed prior to the admission in the HPI only if they contribute data that impacts on t","cbCaidYgjUrBCz4A","https://ap.wps.com/l/cbCaidYgjUrBCz4A","doc",52736,8,"English","en",105,"# Introductory Statement with Chief Complaint\n## Source and Reliability\n## Primary Physician(s)\n## History of Present Illness\n## Past Medical History\n## Medications\n## Allergy/Adverse Reactions to Medications\n## Family History\n## Social history/Habits\n## Review of Systems","[{\"question\":\"What should the introductory chief complaint statement include?\",\"answer\":\"It should briefly explain why the patient presented, including age, gender, pertinent past medical history, major symptoms and duration, and—when possible—the patient’s perspective in the patient’s words.\"},{\"question\":\"How should the History of Present Illness (HPI) be written?\",\"answer\":\"The HPI should be a chronological, narrative prose account that builds an argument for why the patient was admitted, covering symptom timeline, interventions, patient interpretations, onset/quality/severity, and relevant PMH/SH/FH/ROS elements for differential diagnosis.\"},{\"question\":\"What details are required in the medications and allergy sections?\",\"answer\":\"Each medication should include dose, route, and frequency, plus start date or dosage changes when appropriate, including OTC and herbal products. Allergies and adverse reactions to medications must be listed with the relevant reaction information.\"}]","History and Physical Exam Write-up Guidelines | DOC",1788439231,2,{"code":4,"msg":76,"data":77},"ok",{"site_id":69,"language":68,"slug":78,"title":59,"keywords":79,"description":60,"schema_data":80,"social_meta":135,"head_meta":137,"extra_data":139,"updated_unix":73},"history-and-physical-exam-write-up-guidelines","",{"@graph":81,"@context":134},[82,97,117],{"@type":83,"itemListElement":84},"BreadcrumbList",[85,89,91,94],{"item":86,"name":87,"@type":88,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":90,"name":10,"@type":88,"position":74},"https://docshare.wps.com/template/",{"item":92,"name":36,"@type":88,"position":93},"https://docshare.wps.com/template/forms/",3,{"item":95,"name":59,"@type":88,"position":96},"https://docshare.wps.com/template/history-and-physical-exam-write-up-guidelines/194452/",4,{"url":95,"name":59,"@type":98,"image":99,"author":104,"headline":59,"publisher":106,"fileFormat":109,"inLanguage":68,"description":60,"dateModified":110,"datePublished":111,"encodingFormat":109,"isAccessibleForFree":112,"interactionStatistic":113},"DigitalDocument",{"url":100,"@type":101,"width":102,"height":103},"https://docshare.wps.com/thumbnails/history-and-physical-exam-write-up-guidelines/194452.png","ImageObject",442,249,{"name":57,"@type":105},"Person",{"url":86,"name":107,"@type":108},"DocShare","Organization","application/octet-stream","2026-10-07","2026-09-03",true,{"@type":114,"interactionType":115,"userInteractionCount":66},"InteractionCounter",{"@type":116},"ViewAction",{"@type":118,"mainEntity":119},"FAQPage",[120,126,130],{"name":121,"@type":122,"acceptedAnswer":123},"What should the introductory chief complaint statement include?","Question",{"text":124,"@type":125},"It should briefly explain why the patient presented, including age, gender, pertinent past medical history, major symptoms and duration, and—when possible—the patient’s perspective in the patient’s words.","Answer",{"name":127,"@type":122,"acceptedAnswer":128},"How should the History of Present Illness (HPI) be written?",{"text":129,"@type":125},"The HPI should be a chronological, narrative prose account that builds an argument for why the patient was admitted, covering symptom timeline, interventions, patient interpretations, onset/quality/severity, and relevant PMH/SH/FH/ROS elements for differential diagnosis.",{"name":131,"@type":122,"acceptedAnswer":132},"What details are required in the medications and allergy sections?",{"text":133,"@type":125},"Each medication should include dose, route, and frequency, plus start date or dosage changes when appropriate, including OTC and herbal products. Allergies and adverse reactions to medications must be listed with the relevant reaction information.","https://schema.org",{"og:url":95,"og:type":136,"og:title":59,"og:site_name":107,"og:description":60},"article",{"robots":138,"canonical":95},"index,follow",{"doc_id":55,"site_id":69}]