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Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

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History and Physical Note Template

Chief Complaint or Reason for Consult: Why the patient is seeking medical care or the reason

you have been consulted.

History of Present Illness (HPI): History of present illness is the “Who, What, When, Where,

Why, How, How Long” section used to document the patient’s story related to the chief

complaint or consult.

Past Medical History: A list of all medical diagnoses (include pertinent information such as a

new diagnosis). Identify the length of the diagnosis with either year or longevity.

Past Surgical History: A list of all surgeries. Be sure to include the date of the surgery.

Family History: First-degree pedigree medical diagnoses—be sure to include age and cause of

death of family members.

Social History: A synopsis of work, tobacco, alcohol, drug use, marital status, residence, travel,

functional status, and surrogate/advanced directives.

Allergies: A list of medication or food allergies and the type of reaction the patient experiences

when exposed to the foods or medications.

Home Medications: List all home medications and the dosage in milligrams and frequency.

Document adherence, including prn/over-the-counter and how often the patient takes prn

medications.

Hospital Medications: List the name, milligrams, frequency, and route if you are seeing the

patient after being admitted.

Review of Systems: Review of symptoms (told by the patient or family) but organized by

system. Must have 12 systems with at least 2 pertinent +/-

• CONSTITUTIONAL: These are the patient’s answers about general constitutional signs or symptoms.
Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out

functions of daily living.

• EYES: These are the patient’s answers about signs or symptoms that may include the use of glasses, eye
discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light

sensitivity, swelling around the eyes or lids, and visual disturbances.

• EARS, NOSE, and THROAT: These are the patient’s answers about signs or symptoms, including
sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and

abnormalities. It could include nosebleed, postnasal drip, frequent sneezing, frequent nasal drainage,

impaired ability to smell, sinus pain, difficulty breathing, or history of sinus infection and treatment. For

the throat and mouth: sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums,

history of hoarseness, change in voice quality, difficulty in swallowing or inability to taste.

• CARDIOVASCULAR: These are answers by the patient regarding signs and symptoms which may
include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the

fingers or toes, edema, leg pain when walking.

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• RESPIRATORY: These are the patient’s answers about signs or symptoms of the respiratory system.
Some examples may be cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath,

difficulty breathing.

• GASTROINTESTINAL: These are patient’s answers about signs or symptoms of the GI system and
include such things as indigestion or pain associated with eating, burning sensation in the esophagus,

frequent nausea or vomiting, abdominal swelling, changes in bowel habits or stool characteristics, such as

diarrhea or constipation.

• GENITOURINARY: These are the patient’s answers about signs or symptoms of the genitourinary
system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank

pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile

dysfunction, irregular menses, toilet training, or bedwetting.

• MUSCULOSKELETAL: These are the patient’s answers about signs or symptoms of the musculoskeletal
system. Examples include muscle cramps, twitching or pain, limitations on walking, running, or

participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint

movement.

• INTEGUMENTARY: These are the patient’s answers about signs or symptoms of the skin. Some
examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesions, nail

color or texture, breast pain, tenderness or swelling, breast lumps, and history of nipple discharge or

changes.

• NEUROLOGICAL: These are the patient’s answers about signs or symptoms of the neurologic system.
Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions,

memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability

to concentrate, sensory disturbances, motor disturbances, including gait, balance, and coordination, tremor,

or paralysis.

• PSYCHIATRIC: These are the patient’s answers about signs or symptoms of the psychiatric system. Some
examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss

of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment,

restlessness, irritability, and excessive mood swings.

• ENDOCRINE: These are the patient’s answers about signs or symptoms of the endocrine system. Some
examples may be blood sugar readings at home, sudden changes in height or weight, increased appetite or

thirst, intolerance to heat or cold, and changes in hair distribution or skin pigment.

• HEMATOLOGIC/LYMPHATIC: These are the patient’s answers about signs or symptoms of the
hematologic/lymphatic system. Examples include easy bruising, fevers which come and go, swollen glands,

night sweats, and unusual bleeding.

• ALLERGIC/IMMUNOLOGIC: These are the patient’s answers about signs or symptoms of
allergic/immunologic issues. Examples include answers about allergies to medication, foods or other

substances, hives or itching, frequent sneezing, chronic or clear postnasal drip, conjunctivitis, history of

chronic infection, etc.

Physical Exam: What you identify as you assess the patient.

• GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in
no acute distress.

• VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per
minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal

cannula, weight, and BMI.

• HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light
and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good

dentition, no lesions. Tympanic membranes are clear.

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• NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or
tenderness.

• CHEST: Symmetric. Nontender to palpation.

• LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.

• HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.

• BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses.

• ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or
hernia. Bowel sounds are present. No CVA tenderness or flank mass.

• GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin
lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended

bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal.

• GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses.
Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus

are normal.

• RECTAL: [Male]. Normal sphincter tone. No masses. Prostate is smooth and nontender and without
nodules or fluctuance.

• RECTAL: [Female]. Normal sphincter tone. No masses or tenderness.

• EXTREMITIES: No cyanosis, clubbing, or edema.

• NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through
XII are intact. Deep tendon reflexes are intact.

• PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact.
Appropriate mood and affect.

• SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No
onychomycosis. Address surgical wounds and drains.

• LYMPHATICS: No cervical, axillary, or groin adenopathy is noted.

Laboratory and Radiology Results: List all data available when seeing the patient’s normal and

abnormal results. Include all of the CBC and electrolytes (all elements tell a story).

Assessment: (Provide three references)

• Differential Diagnoses: A differential diagnosis are potential diagnoses related to the
chief complaint and assessment. Provide a rationale for the working diagnosis which is

one of the differential diagnoses. Include the ICD codes. List at least three working

diagnoses related to the admission or consult and identify one as being the primary

diagnosis until ruled out.

• Acute and Chronic Medical Conditions: What needs to be addressed while admitted, in
order of priority.

Treatment Plan: (Provide three references)

What orders are you starting? What medications with dose and frequency? What consults?

Education topics? Discharge plan?

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Geriatric Considerations:

Based on the age, address any differences in the treatment if the patient was younger or older.

References: List references in APA format.

Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:


History and Physical Note

1. Chief complaint/reason for admission/visit/consult.

2. HPI for the H&P or consult notes.

3. Medical, surgical, family, social, and allergy history.

4. Home medications, including dosages, route, frequency, and current medications, if a consultation note.

5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).

6. Vital signs and weight.

7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.

8. Lab/Imaging/Diagnostic test results (including date).


Assessment and Clinical Impressions

1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.

2. Include a complete list of all diagnoses that are both acute and chronic.

3. List the differential diagnoses and chronic conditions in order of priority.


Plan Component Management and Plan Criteria Incorporation

1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.

2. Discuss disposition and expected outcomes.

3. Identify and address health education, health promotion, and disease prevention.

4. Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.


General Requirements

This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the Student Success Center page under the AGACNP tab.

Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

History and Physical Note

12 points

Criteria Description

History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)

5. Target

12 points

The history and physical note is thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The history and physical note is provided with appropriate details and support.

3. Approaching

9.6 points

The history and physical note is present, but only minimal detail or support is provided.

2. Insufficient

6 points

The history and physical note is incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The history and physical note is not included.

Assessment and Clinical Impressions

12 points

Criteria Description

Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)

5. Target

12 points

The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The assessment and clinical impressions are provided with appropriate details and support.

3. Approaching

9.6 points

The assessment and clinical impressions are present, but only minimal detail or support is provided.

2. Insufficient

6 points

The assessment and clinical impressions are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The assessment and clinical impressions are not included.

Plan Component Management and Criteria

12 points

Criteria Description

Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)

5. Target

12 points

The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

10.8 points

The plan component management and plan criteria incorporation are provided with appropriate details and support.

3. Approaching

9.6 points

The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.

2. Insufficient

6 points

The plan component management and plan criteria incorporation are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The plan component management and plan criteria incorporation are not included.

Peer-Reviewed Articles

6 points

Criteria Description

Peer-Reviewed Articles

5. Target

6 points

Three peer-reviewed articles are included.

4. Acceptable

5.4 points

N/A

3. Approaching

4.8 points

N/A

2. Insufficient

3 points

Fewer than three peer-reviewed articles are provided.

1. Unsatisfactory

0 points

Three peer-reviewed articles are not included.

Mechanics of Writing 

6 points

Criteria Description

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

5. Target

6 points

No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.

4. Acceptable

5.4 points

Few mechanical errors are present. Suitable language choice and sentence structure are used. 

3. Approaching

4.8 points

Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.

2. Insufficient

3 points

Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent. 

1. Unsatisfactory

0 points

Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout. 

Format/Documentation 

12 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target

12 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

4. Acceptable

10.8 points

Appropriate format and documentation are used with only minor errors.

3. Approaching

9.6 points

Appropriate format and documentation are used, although there are some obvious errors.

2. Insufficient

6 points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident. 

1. Unsatisfactory

0 points

Appropriate format is not used. No documentation of sources is provided. 

Total 60 points

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