History and physical notes are created for
a variety of types of clinical encounters including primary care provider visits,
new patient visits to specialists, and some consult notes for
hospitalized patients. These notes are also known as HNP notes
and typically have the following sections. A description of the patient's chief
complaint, a history of present illness or HPI, a review of systems or ROS,
details of the physical exam and a section describing the provider's
assessment and plan. There may also be sections describing
the patient's past medical history, social history and
their family health history. Details available elsewhere in
the record like vital signs, laboratory test results,
drug allergies and the medications a patient is taking
may also be included in this note. Diving a little deeper, chief complaint is a short indication
of the reason for the patient's visit. History of present illness on the other
hand is a longer narrative description of the problem. With a summary of the relevant
aspects of a patient's health history to the chief complaint. There may be a review of
systems that separates out each of the symptoms a patient may or may
not be having by different organ systems. For example, chest pain or heart palpitations would be recorded
in the cardiovascular section, while cough and shortness of breath
would be recorded in pulmonary. Review of Systems can help providers
make sense of more complex cases that are difficult to fully describe
in the history of present illness. If a physical exam is performed
the results are typically recorded in an organized approach like
review of systems, including any or all of these areas. Finally, the assessment and plan section describes the physician's
assessment of the diagnoses or potential diagnoses that may describe
the symptoms the patient is having. This section also describes
the plan to test or treat the patient for those diseases. This general framework is called
a SOAP note, standing for subjective, objective,
assessment, and plan. Subjective are those things that
are influenced by personal experience, like the chief complaint and
history of present illness. Objective are those things
that are measured or observed like the physical exam,
laboratory testing and radiology data. You may see these section
headers used in clinical notes, though that is less common.