H&P

Chief Complaint

"[Chief complaint in patient's own words]" (Direct patient quote describing primary symptom causing patient to seek care.)

Source & Reliability

[Source and reliability of patient information] (If patient isn't reliable or information comes from another source, specify and explain reason.)

History of Present Illness (HPI)

[Patient's identifying data, age, gender, and pertinent past medical history]. (Present symptoms chronologically and clearly. Detail symptom onset, duration, frequency, severity, character, location, aggravating/alleviating factors, and associated symptoms. Include patient's perspective and relevant PMH, FH, SH. Mention pertinent positives and negatives from ROS explicitly stated in transcript.)

Past Medical History

• [Medical conditions with onset dates, hospitalizations, complications, treatments]
• [Surgical history with dates and indications]
• [OB/Gyn history including pregnancies (G,P), menstrual history, birth control]
• [Psychiatric history with dates, hospitalizations, treatments]
• [Age-appropriate health maintenance and immunizations]
• [Significant childhood illnesses]

Medications

• [Medication name, dose, route, frequency] (Include OTC and supplements explicitly mentioned in the transcript.)

Allergies

• [Allergies and nature of reaction]

Family History

• [Health conditions or cause of death of immediate family]

Social History

[Occupation, education, living situation, tobacco/alcohol/drug use, sexual history, safety concerns, advanced directives, functional status, significant life experiences] (Include explicitly mentioned information only.)

Review of Systems

• [System: Pertinent positives or negatives explicitly stated in the transcript] (Only list systems explicitly reviewed.)

Physical Examination

• [Vital signs including Temperature, Pulse, BP, RR, Pain scale, O2 saturation]
• [General appearance: Patient's overall condition and appearance]
• [HEENT: Explicit findings]
• [Neck: Explicit findings]
• [Heart: Explicit findings]
• [Lungs: Explicit findings]
• [Abdomen: Explicit findings]
• [Extremities: Explicit findings]
• [Neurological: Explicit findings]
• [Musculoskeletal: Explicit findings]
• [Vascular: Explicit findings]
• [Skin: Explicit findings]

Data Collection

• [Lab and radiological data explicitly stated, including clinician interpretation]

Problem List

• [List of identified patient problems prioritized by importance]

Summary Statement

In summary, [Provide 1-2 sentence impression restating basic identifying information (e.g., age, gender), pertinent medical/family/social history, expanded chief complaint, and most relevant review of systems findings on presentation. Highlight the most important findings from the physical exam, labs, and imaging studies that directly support the differential diagnosis.] (Include only explicitly mentioned and pertinent information.)

Assessment & Plan

(Organize assessment and plan by problem identified in the problem list.)

Problem #1: [Diagnosis]
Differential diagnosis includes [Most likely, Alternative, Do Not Miss]. Explain reasoning for likelihood, include supporting/refuting evidence from history, exam, and labs explicitly mentioned. Outline diagnostic and treatment plans, patient education.

Problem #2: [Diagnosis] (Repeat structure only if additional problems discussed.)

(Only include explicitly discussed items from transcript. Do not speculate or add unmentioned details.)