H&P (History and Physical)
Formal Definition
The comprehensive admission note documenting a patient's history, physical exam, labs/imaging, assessment, and plan.
How It's Used on the Ward
"Write the H&P" - your first documentation assignment as a student.
Example
"A good H&P: "CC: Chest pain. HPI: [story]. PMH/PSH/Meds/Allergies/FH/SH. ROS: [pertinent]. Exam: [findings]. Data: [labs/imaging]. A/P: [reasoning + plan].""
Clinical Context
The H&P is your most important written document. It should be so complete that someone could take over the patient's care from reading it alone.
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