Student History & Physical (Admission)

Date/Time of Encounter: [Date and time of patient evaluation]
Date/Time Authored: [Date and time note is authored]
Location: [Unit / room / bed]
Service/Team: [Admitting service or team name]
Author: [Medical student name and level]
Supervising Resident: [Resident name and role]
Attending of Record: [Attending name]
Primary Care Clinician: [Name and contact information / unknown]
Source(s) of History: [Patient / family / interpreter / chart] (State reliability and any limitations such as altered mental status, language barrier, or critical illness; include interpreter ID if applicable.)

Chief Concern

[Chief concern in patient's own words if clinically meaningful; otherwise concise clinical phrasing] (Single sentence; include both if two unrelated issues drive admission.)

One-Liner

[Age], [relevant gender], [key comorbidities], [baseline functional status if relevant], presenting with [immediate reason for admission].

History of Present Illness

[Chronological narrative of symptom onset, time course, severity, location, quality, progression, context, exacerbating/relieving factors, associated symptoms, pertinent negatives, exposures/triggers, and baseline vs current function; include home interventions and response.] (Organize into clear paragraphs; use direct quotes sparingly for high-salience statements.)

Pre-hospital and ED Course: [EMS and ED vitals, key labs/imaging, treatments with doses, response, consultations, and rationale for admission vs discharge.]

(If history is limited, document the reason and alternative sources used.)

Review of Systems

(Include only systems actually reviewed. Omit unassessed systems rather than documenting false negatives. If comprehensive ROS required locally, include all systems and mark any not obtained with reason.)

• Constitutional: [Fever/chills, weight change, fatigue]
• HEENT: [Headache, vision changes, hearing changes, sore throat, rhinorrhea]
• Cardiovascular: [Chest pain, palpitations, edema, orthopnea, PND]
• Respiratory: [Dyspnea, cough, sputum, wheeze, hemoptysis]
• Gastrointestinal: [Nausea, vomiting, abdominal pain, diarrhea, constipation, melena/hematochezia]
• Genitourinary: [Dysuria, frequency, hematuria, retention]
• Neurologic: [Focal weakness, numbness, dizziness, syncope, seizures]
• Psychiatric: [Mood, anxiety, suicidality, hallucinations]
• Skin: [Rash, wounds, bruising]
• Endocrine: [Polyuria, polydipsia, heat/cold intolerance]
• Hematologic: [Easy bruising/bleeding, blood clots]
• Musculoskeletal: [Myalgias, arthralgias, back pain]

Past History

• Past Medical History: [Active chronic diagnoses and major resolved problems with ongoing relevance] (Include key details when known: EF, CKD stage, last A1c.)
• Past Surgical/Procedural History: [Procedure and approximate date] (Note complications relevant to current care.)
• Psychiatric History: [Diagnoses, prior hospitalizations, suicide attempts, treatments] (Include when relevant to safety, capacity, adherence, or current complaint.)
• OB/GYN History: [G/P, LMP, contraception, pregnancy status] (Include when relevant to current presentation or treatment decisions.)

Medications

• Home Medications: [Medication name — dose — route — frequency] (List each on its own line; include PRN indications and actual use patterns when relevant.)
• OTC/Supplements/Herbals: [List with details when relevant]
• Adherence: [Adherence pattern and barriers]
• Last Doses of Safety-Critical Medications: [Anticoagulants/antiplatelets, insulin, opioids, immunosuppressants]
• Medication Reconciliation Status: [Complete / partial / uncertain] (State confidence level and sources checked: patient, family, pharmacy, PDMP, prior records.)

(Do not guess unknown doses or frequencies. For safety-critical medications, explicitly document if information is unavailable and why.)

Allergies

• [Substance] — [Reaction] — [Severity] (Differentiate true allergy vs intolerance/side effect when known.)

(If none: No known drug allergies. If allergy history unavailable, document why.)

Family History

• [Relevant familial conditions and relationships with ages at diagnosis] (Include items pertinent to differential or management: premature CAD, sudden death, thrombophilia, cancer syndromes, heritable diseases. Omit section if noncontributory after review.)

Social History

• Living Situation and Supports: [Housing, caregivers, family supports]
• Functional Status: [ADLs, IADLs, mobility devices, baseline oxygen requirements]
• Tobacco: [Status, quantity, duration, quit attempts]
• Alcohol: [Quantity, pattern, last use, withdrawal risk]
• Other Substances: [Type, route, frequency, last use, interest in treatment]
• Occupation/Exposures: [Current/previous work; relevant exposures]
• Social Drivers of Health: [Transportation, finances, medication access, food security]
• Safety: [Firearms access, IPV/abuse/neglect concerns] (Include when relevant to behavioral health or safety screening.)

Physical Exam

• Vitals: T [temp] | HR [rate] | BP [pressure] | RR [rate] | SpO2 [saturation] on [room air / O2 device and flow] | Pain [score]
• General: [Appearance, distress level]
• HEENT: [Pupils, sclera, oropharynx, mucous membranes]
• Neck: [Supple, JVP, lymphadenopathy]
• Cardiovascular: [Rate/rhythm, murmurs, pulses, edema]
• Respiratory: [Effort, breath sounds]
• Abdomen: [Inspection, bowel sounds, tenderness, organomegaly]
• Extremities/MSK: [Deformities, range of motion, tenderness]
• Skin: [Lesions, rashes, turgor]
• Neurologic: [Mental status, cranial nerves, motor, sensation, reflexes, coordination]
• Psychiatric: [Mood, affect, thought process, insight/judgment]
• Lines/Tubes/Drains: [IVs, urinary catheter, drains, CVC, arterial line, pacer/ICD]

(Document only what was meaningfully examined. If an exam is deferred, document reason. Do not clone normals for unexamined systems.)

Data Review

• Laboratory Data: [Key abnormalities and pertinent normals with dates and trends]
• Microbiology: [Cultures and susceptibilities; PCR/antigen testing results]
• Imaging: [Study — date — key findings and official impression]
• Cardiac Studies: [ECG interpretation, troponins, echocardiography]
• Prior Records Reviewed: [Source and salient findings]
• Pending Studies: [Tests ordered and anticipated impact on management]

(If adding personal interpretation, label clearly. Avoid contradicting official reports without explanation.)

Assessment

[Synthesis paragraph restating clinical picture with key supporting findings; name the leading working diagnosis or syndromic framing; include top alternatives if uncertainty remains; describe severity/trajectory and immediate risks.]

Problem-Based Assessment & Plan

(Number problems in descending order of acuity.)

1. [Problem 1]: [Brief assessment including current status: improving / stable / worsening, with key supporting data.]

   • Differential: [Appropriately sized, ranked differential]
   • Diagnostics: [Tests with rationale and timing; thresholds for escalation]
   • Therapeutics: [Medications with doses/routes/frequencies; non-pharmacologic interventions]
   • Monitoring: [Parameters, frequency, and specific action thresholds]
   • Consults: [Service and specific clinical question]

2. [Problem 2]: [Brief assessment with status and supporting data.]

   • [Differential, diagnostics, therapeutics, monitoring, consults as above]

3. [Additional problems as needed]

Cross-Cutting Care Elements

• VTE Prophylaxis: [Pharmacologic / mechanical / contraindicated] (Include agent, dose, and contraindications considered.)
• Glycemic Management: [Regimen and targets] (Include if diabetic or hyperglycemic.)
• Code Status: [Full code / DNR / DNI / other] (State whether confirmed today, participants in discussion, and documentation completed. If unknown, document attempts to clarify.)
• Nutrition: [Diet order and rationale; NPO status if applicable]
• Activity: [Ambulation status, PT/OT, fall precautions]
• Lines/Tubes Review: [Necessity and removal plan]
• Disposition Planning: [Anticipated disposition, barriers, discharge criteria, expected timeline]

Supervision and Attestation

Student Declaration: This note was authored by [Student name, role, contact information] for supervising physician review and is not a final clinical document.

Resident Review: Reviewed by [Resident name] on [date/time]. [Summary of major edits or discussion points] (Optional.)

Teaching Physician Attestation:

• I personally reviewed the student's documentation and edited as needed.
• I personally performed or re-performed key portions of the history and physical examination.
• I personally participated in medical decision-making and management of this patient.
• I [agree with / have amended] the assessment and plan as documented above.
• Attending Addendum: [Patient-specific clarifications, corrections, or updates]

(Attestation must be individualized and patient-specific; generic macro alone is insufficient for billing compliance.)