During my Internal Medicine training, I wrote 100s of History and Physicals (H&Ps).
Now as a Cardiology fellow, I read every single H&P for a new consult.
Here are some tips and tricks for effective H&Ps.
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
Now as a Cardiology fellow, I read every single H&P for a new consult.
Here are some tips and tricks for effective H&Ps.
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
1) Chief Concern:
- This should be the 1st thing listed at the top of the note
- This answers the question, "What made the patient decide to seek medical care?"
- It can be brief, such as abdominal/chest pain or nausea/vomiting
- It is the introduction for the patient's story
- This should be the 1st thing listed at the top of the note
- This answers the question, "What made the patient decide to seek medical care?"
- It can be brief, such as abdominal/chest pain or nausea/vomiting
- It is the introduction for the patient's story
2) HPI:
- Tell the story in the patient's words
- It doesn't have to be a novel!
- Usually 4-6 sentences of what the patient is feeling can thoroughly explain the context
- Include pertinent descriptions of the chief concern; i.e. duration, severity, quality of their symptoms
- Tell the story in the patient's words
- It doesn't have to be a novel!
- Usually 4-6 sentences of what the patient is feeling can thoroughly explain the context
- Include pertinent descriptions of the chief concern; i.e. duration, severity, quality of their symptoms
3) Previous Visits:
- Include a few sentences about previous hospitalizations, ER visits, or clinic visits.
- Even 1-2 sentences previous care will provide useful insight
- As a consultant, this is super helpful and shows that you have thoroughly reviewed the chart
- Include a few sentences about previous hospitalizations, ER visits, or clinic visits.
- Even 1-2 sentences previous care will provide useful insight
- As a consultant, this is super helpful and shows that you have thoroughly reviewed the chart
4) ER Work-Up:
- Try to include their initial vital signs (provides hemodynamic reference), relevant labs on presentation
- Imaging tests done with brief description (CXR, CT A/P, EKG)
- Include medications/fluids given
- Can be last part of HPI and include a paragraph ๐
- Try to include their initial vital signs (provides hemodynamic reference), relevant labs on presentation
- Imaging tests done with brief description (CXR, CT A/P, EKG)
- Include medications/fluids given
- Can be last part of HPI and include a paragraph ๐
An example:
In the ER, patient was hemodynamically stable with initial HR: 78, BP: 111/70, saturating 98% on room air. Labs significant for WBC: 8, Hemoglobin: 10 (baseline ~9-10, Creatinine 1.1, troponin 52-50). EKG showed NSR w/o ischemic changes. ASA 324 mg provided
In the ER, patient was hemodynamically stable with initial HR: 78, BP: 111/70, saturating 98% on room air. Labs significant for WBC: 8, Hemoglobin: 10 (baseline ~9-10, Creatinine 1.1, troponin 52-50). EKG showed NSR w/o ischemic changes. ASA 324 mg provided
5) Home Medication Reconciliation
- If possible, when the H&P has a list of the patient's home medications listed, this is a great help as a consultant.
- This allows for an understanding what the patient was actually taking at home (rather than prescribed)!
- If possible, when the H&P has a list of the patient's home medications listed, this is a great help as a consultant.
- This allows for an understanding what the patient was actually taking at home (rather than prescribed)!
6) Assessment and Plan:
- As a consultant, I like to review the thought process of the primary team and the overall, holistic picture of the patient
- Effective H&P are often problem-based and have supporting evidence for the diagnosis and plans listed to address the problems.
- As a consultant, I like to review the thought process of the primary team and the overall, holistic picture of the patient
- Effective H&P are often problem-based and have supporting evidence for the diagnosis and plans listed to address the problems.
6) One format for problem-based that I like:
//Problem
- Evidence 1
- Evidence 2
Plan:
- Solution 1
//HFrEF Exacerbation
- Presented with DOE, PND, weight gain
- Labs on admission w/ BNP: 5000
- TTE w/ EF 25%
Plan:
- IV Lasix ordered
- Cardiology consulted
//Problem
- Evidence 1
- Evidence 2
Plan:
- Solution 1
//HFrEF Exacerbation
- Presented with DOE, PND, weight gain
- Labs on admission w/ BNP: 5000
- TTE w/ EF 25%
Plan:
- IV Lasix ordered
- Cardiology consulted
7) Contact Information:
- If you have a patient that needs additional assistance from family member and have listed their contact information, this is invaluable!
- As an internist, you are often the first one seeing the patient and may have this information
- If you have a patient that needs additional assistance from family member and have listed their contact information, this is invaluable!
- As an internist, you are often the first one seeing the patient and may have this information
I hope this helps! Remember it takes 100s of H&P to develop your own system and become more efficient. Find what works for you and perfect it!
Remember many people (including consultants, RN, ancillary staff) will read your H&P and try to share your thoughts effectively!
Remember many people (including consultants, RN, ancillary staff) will read your H&P and try to share your thoughts effectively!
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