C C 306M Chapter Notes - Chapter 2: Ct Scan, Hospital Records, Radiography
20 Aug 2013
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History and physical (h&p) documents the patient"s medical history and findings from the physical examination. Recorded at a new patient visit or as part of a consultation. Usually the first document generated when a patient presents for care. Documents subjective information from patient"s personal statement about his or her medical history. Begins with chief complaint (cc) *patient"s reason for seeking medical care: usually brief, recorded in patient"s own words indicated by quotation marks. Then present illness (pi) or history of present illness (hpi: noting the duration and severity of the complaint, notations about the patient"s symptoms (sx) Then patient"s past history (ph) or past medical history (pmh: patient"s past illnesses starting with childhood. Includes surgical operations, injuries, medications, physical defects and allergies. Include state of health of immediate family members. Then social history (sh: patient"s recreational interests, hobbies, use of tobacco and drugs (even alcohol) Then occupational history (oh: record of work habits that may involve health risks.
