H&P Template

Date of Note: 

Chief Complaint: 

History of Present Illnesses: 

Past Medical History: 

Allergies: 

Medications: 

Past Surgical History: 

Social History: 

Review of Systems: as above

Family History: 

Physical Examination: 

Vital Signs

Temp /  HR / RR / BP / O2 Sat 

 /  /  /  /

GEN: NAD, Laying Comfortably in bed

HEENT: PERRLA, no jaundice

CV: rrr, no mrg, +S1, S2

PULM: CTAB, no crackles, wheezing, rales

ABD: soft, NTND, no rebound, no guarding

EXT: 2+ peripheral pulses. No edema b/l. 

SKIN: no petechiae, no rash

NEURO: A&O x 3.
GU/Pelvic/rectal: deferred

Test Results: 
Labs

BMP

Na / K / Cl / HCO3 / BUN / Cr < Glu 

  /  /  /  /  /  <  

CBC

WBC > Hgb / Hct < Plts

 >  /  < 

LFTs

Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos

 /  /  /  /  /  <

IMAGING


Assessment and Plan: 

  yo M/F with PMH * presents with 

# FEN/GI: regular diet

# DVT PPX: heparin Subq

# Code Status: FULL CODE

# Dispo: Pending medical work-up

# Emergency Contact: 

[ ] Central line, PICC line, or dialysis catheter present and indicated 

PLEASE SEE ATTENDING ADDENDUM 
DISCUSSED WITH DOCTOR: Dr. Richman

Used Interpreter - Name: 
Used HCN - Interpreter ID #: 
Interpretation language: