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History and Physical

History and Physical Note Generator

An admission conversation is recorded, and the account, the examination and the plan arrive as sections rather than one undivided page.

  • Chief complaint kept in the patient's words
  • The illness history rebuilt as a timeline
  • Background details pulled out as they surface
  • Exam findings kept beside the account
Draft a History and Physical

What a History and Physical Has to Hold

A long note, assembled from a wandering talk.

A history and physical note is the fullest document most patients generate. It carries why they came, how the problem unfolded over time, what their body has been through before, what they take, what they react to, what examination found, and what is planned. None of that arrives in order. A history and physical generator does the assembling: the encounter is recorded once and the pieces are drawn out of it afterwards, instead of being chased down during a conversation that will not stop for a form.

What the History and Physical Generator Fills

The sections an admission note is expected to contain.

Chief complaint as stated

The reason given for coming, recorded in the patient's own phrasing rather than translated into a diagnosis.

Illness history as a timeline

Onset, duration, what makes it worse, what helps, ordered into a story the history and physical can follow.

Background gathered where it appears

Past conditions, operations, family history, social circumstances, current medication and allergies, picked up as the conversation offers them.

Examination findings kept distinct

Observations recorded while examining sit apart from the account, so the two do not blur.

More than one source allowed

A relative supplying the timeline, or old notes read aloud on a transfer, are attributed rather than quietly merged into the patient's voice.

Specialty sections added on request

Instructions can extend or reorder the structure for a specialty, while keeping the history and physical recognisable to anybody reading it.

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An admission is rarely tidy

Patients arrive with a complaint, a good deal of uncertainty and a relative who wants to help. What they say first is not always what brought them in, and the detail that changes everything often turns up in the last minute of the conversation. A history and physical written during the encounter therefore misses things, while one written the next morning invents them.
Start the Note
An admission conversation in progress
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The chief complaint is not the diagnosis

Writing the reason for attendance in clinical language is a small act of interpretation, and it is better done deliberately than by accident. A history and physical is easier to audit when the first line says what the patient reported and the assessment appears further down, where the reasoning that supports it can be read beside it. Keeping the two apart also makes a later revision simpler to explain.
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Stated complaint kept apart from diagnosis
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History is a sequence, not a list

Onset, course and duration only mean something in relation to each other, and a conversation gives them out of order: the patient mentions a scan from two years ago while describing last night. Rebuilding the sequence afterwards is a task the recording does well, because the answers are all present and merely out of position. A captured timeline also shows where the account contradicts itself.
Start the Note
Dates pulled into chronological order
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Medication and allergy lists deserve suspicion

What a patient takes is reported approximately, and what they react to is reported with feeling rather than precision. A history and physical records what was said and leaves the pharmacist or the clinician to weigh it, but the wording matters: a rash and a swollen throat are not the same entry. Keeping the original phrasing makes the difference in the record visible.
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Medication and allergy wording kept exact
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One encounter, several voices

Information arrives from whoever is in the bay. A partner remembers the operation the patient has forgotten, a transfer note is read out by a colleague, and an old discharge letter gets summarised out loud. A history and physical assembled from that material needs to say who supplied what, or a detail from a relative is attributed to the patient for the rest of the admission.
Start the Note
Several sources marked by speaker
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The note is long because it has to be

A history and physical is the heaviest piece of documentation a patient generates, and every section exists because somebody at some point needed it. That is also why drafting from a recording pays: the talking already happened, and the labour was never the medicine. It was the typing, the reordering, and the searching for what had been said twenty minutes earlier.
Start the Note
A long note built from one recording

How to Build a History and Physical

Record the encounter once, then assemble the note.

Step 1

Capture the admission interview

Record the encounter in the browser, or upload a file if it was already captured on a ward device.

Step 2

Let the sections take shape

The account is set down and distributed across the history and physical headings, with examination kept apart.

Step 3

Fill the gaps by hand

Add anything never said aloud, reorder what the history and physical got the wrong way round, and the note is ready.

Who Writes History and Physical Notes

Four roles that meet patients on the way in.

PD

Priyanka Deshpande

Acute Medical Registrar

On a take day I do eleven of these. The draft is never the finished note, but it is always a better starting point than eleven blank pages and a pen.

GN

Grzegorz Nowicki

Admissions Nurse

Relatives fill in gaps the patient cannot. Seeing their answers marked separately in the note means the next shift knows which parts came from whom.

AC

Amara Chidozie

Surgical Resident

Our history and physical adds a system at the end. Custom instructions put it there in the right order every time, which is more than I manage when I am tired.

HB

Halvard Bergström

Clinical Governance Lead

We reviewed a batch of generated drafts against the recordings. The structure held, the timeline held, and the corrections were in the places we would expect.

Questions About History and Physical Notes

What the draft covers and where it stops.

Draft a History and Physical

Record the admission interview and the note comes back sectioned, with the account, the examination and the plan in their own places.

Start the Note
History and Physical

Assembled from the Encounter

One recorded admission yields the account, the examination and the plan, each in the section a history and physical expects.