H&P (History & Physical) Note: Structure and Sections
Comprehensive new-patient workup. Notermed's built-in H&P (History & Physical) Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the H&P (History & Physical) Note contains
7 sections, in the order the note puts them, and what each one takes from the visit.
- 1
History of Present Illness
- Chief complaint in the patient own words
- Onset and how long symptoms have lasted
- Timing, location, quality, severity, and context
- What worsens or relieves symptoms, and self-treatment tried
- How symptoms have changed over time
- Prior similar episodes, their management and outcome
- Impact on work, home, and physical activity
- Associated or systemic symptoms
- 2
Past Medical History
- Past illnesses, surgeries, and hospitalizations
- Current medications with dose and frequency
- Allergies and the reaction each caused
- Family history relevant to the presentation
- Smoking pack-years and quit date, alcohol, drugs
- Occupation, occupational exposures, and living situation
- Immunization history
- Other relevant background
- 3
Review of Systems (ROS)
- General: fever, chills, night sweats, weight change, fatigue
- HEENT: congestion, post-nasal drip, hoarseness, headache
- Cardiovascular: chest pain, palpitations, syncope, leg edema
- Pulmonary and respiratory: cough, dyspnea, wheeze, sputum, hemoptysis
- Sleep: snoring, witnessed apneas, daytime sleepiness, CPAP or BiPAP use
- Gastrointestinal: nausea, vomiting, abdominal pain, reflux
- Genitourinary: frequency, urgency, dysuria, hematuria
- Gynaecological: menstrual irregularity, pelvic pain, pregnancy status
- Musculoskeletal: joint pain, muscle weakness, back pain, stiffness
- Skin: rashes, lesions, itching, cyanosis, clubbing
- Allergy and immunologic: allergies and reactions, allergic rhinitis, triggers
- Endocrine: thyroid symptoms, diabetes, blood sugar control
- Hematologic and oncologic: bruising, bleeding, clots, malignancy history
- Central nervous system: dizziness, seizures, numbness, memory changes
- Psychiatric: mood, anxiety, depression, sleep disturbance, panic attacks
- 4
Physical Examination
- Blood pressure, heart rate, respiratory rate, temperature
- Oxygen saturation
- Findings by system examined
- Whether a finding is per patient report or per examination
- 5
Investigations
- Tests already performed
- Results available at the visit
- 6
Impression & Plan
- Each issue discussed, numbered separately
- Impression or likely diagnosis for that issue
- ICD-10 code when stated, flagged for billing verification
- Differentials the clinician listed
- Investigations ordered
- Treatments prescribed or advised
- Referrals made
- Advice, education, or safety netting given
- 7
Next Steps
- Review plans and follow-up interval
- Patient instructions for self-care or monitoring
- Red flags that should prompt further care
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the H&P (History & Physical) Note
What sections does the H&P note contain?
Seven, in order: History of Present Illness, Past Medical History, Review of Systems (ROS), Physical Examination, Investigations, Impression and Plan, and Next Steps. The review of systems covers fifteen headings, from general and HEENT through to psychiatric.
What happens to a section nobody discussed?
It is left out of the draft rather than padded. If the visit never covered a review-of-systems heading, that heading does not appear at all, and nothing is written in to fill it.
Does the H&P record ICD-10 codes?
Only where one was stated. Impression and Plan numbers each issue separately with the impression for that issue, and an ICD-10 code appears there when the clinician gave it, flagged for billing verification. Notermed does not look a code up for you.
Who is responsible for the finished workup?
The clinician who signs it. Notermed produces a draft from the visit and nothing more; the note stays a draft until it is reviewed and signed, and signing is what makes it part of the record.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the H&P (History & Physical) Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.