History and physical (H&P) template, with an admission example
Used by: Admitting physicians, hospitalists, residents and consultants.
The history and physical is the foundation note of an admission. Every later progress note and the discharge summary build on it, so it has to be complete: why the patient is here, what else they carry, what you found, and the plan for each problem.
The template below follows the standard admission order. The example is written for an invented patient.
The template, section by section
Chief complaint and HPI
Why the patient presented, and the story of the illness in time order, including what happened in the emergency department.
- Chief complaint
- HPI with timeline
- ED course and treatments given
Past history
Medical, surgical, family and social history, medications and allergies.
- Past medical history
- Past surgical history
- Home medications with doses
- Allergies and reactions
- Social history: tobacco, alcohol, substances, living situation, function
- Family history
Review of systems
Pertinent positives and negatives by system.
- Pertinent positives
- Pertinent negatives
Physical examination
Vital signs and a complete examination.
- Vital signs
- General
- HEENT, neck, cardiovascular, respiratory, abdomen, extremities, skin, neurologic
Data
Labs, imaging, ECG and other results, with the ones that drive decisions called out.
- Labs
- Imaging
- ECG
- Microbiology
Assessment and plan
A one-line summary, then each problem with its reasoning and plan, plus prophylaxis, code status and disposition.
- One-line summary
- Problem-based assessment and plan
- VTE prophylaxis
- Code status
- Expected length of stay and reasons
History and physical (H&P) example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Chief complaint
Shortness of breath for 4 days.
HPI
71-year-old with heart failure with reduced ejection fraction (EF 30% on last echo), hypertension and type 2 diabetes presenting with 4 days of progressive dyspnea on exertion, two-pillow orthopnea and leg swelling. Reports about 4 kg weight gain over a week and running out of furosemide 6 days ago. No chest pain, fever or cough. In the ED: BP 158/92, SpO2 90% on room air improved to 95% on 2 L, BNP elevated, chest X-ray with pulmonary vascular congestion and small bilateral effusions. Received furosemide 40 mg IV with 900 mL urine output.
Past history
PMH: HFrEF, hypertension, type 2 diabetes, CKD stage 3a. PSH: cholecystectomy. Medications: furosemide 40 mg daily (not taking for 6 days), carvedilol 12.5 mg twice daily, sacubitril-valsartan 49-51 mg twice daily, metformin 1000 mg twice daily. Allergies: none known. Social: former smoker, quit 10 years ago; no alcohol; lives with spouse, independent. Family: father with coronary disease.
ROS
Positive for dyspnea, orthopnea, edema. Negative for chest pain, palpitations, syncope, fever.
Exam
T 36.8, BP 150/88, HR 92, RR 22, SpO2 95% on 2 L. Mild respiratory distress. JVP 12 cm. Regular rhythm, no murmur. Crackles at both bases. Abdomen soft. 2+ pitting edema to the knees bilaterally. Alert and oriented.
Data
Na 134, K 4.3, creatinine 1.5 (baseline 1.3), glucose 188, troponin flat at two checks below the 99th percentile, BNP elevated. ECG: sinus rhythm, no acute ST changes. CXR: vascular congestion, small bilateral effusions.
Assessment and plan
71-year-old with HFrEF admitted with acute on chronic systolic heart failure, likely precipitated by stopping furosemide.
1. Acute on chronic HFrEF: furosemide 40 mg IV twice daily, strict intake and output, daily weights, 2 g sodium and 1.5 L fluid restriction, BMP twice daily during diuresis. Continue carvedilol and sacubitril-valsartan while blood pressure allows. Wean oxygen to keep SpO2 at or above 92%.
2. AKI on CKD 3a: creatinine 1.5 from 1.3, likely congestive. Trend with diuresis, avoid nephrotoxins.
3. Type 2 diabetes: hold metformin while creatinine is above baseline; sliding-scale insulin, check A1c.
4. Medication access: social work and pharmacy to address the furosemide refill gap before discharge.
VTE prophylaxis: enoxaparin. Code status: Full Code, confirmed with patient. Expected stay of at least two midnights for IV diuresis and monitoring of renal function and oxygen needs.
Tips from practice
- Lead the assessment with a one-line summary; consultants and cross-cover read that line first.
- State code status explicitly at admission.
- Document why the stay is expected to cross two midnights when it is, in clinical terms.
- Medication doses at home belong in the H&P; reconciliation at discharge depends on them.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
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Questions
- What is the difference between an H&P and a progress note?
- The H&P is the complete note at the start of an admission or a new consult. Progress notes document each day after it and refer back to it.
- Does an H&P need a full review of systems?
- Document the pertinent positives and negatives that bear on the presentation. Requirements for billing levels are set by medical decision making or time.
- Can an AI scribe write an admission H&P?
- Yes. Scribeable writes admission H&Ps from the recorded or dictated encounter and the chart, in the Hospital Medicine template, and suggests the codes for you or your coder to check.
Reviewed 2026-11-08.