How to Write a History and Physical: Template and Example

A history and physical template organizes the patient’s story, relevant background, physical examination, investigation results, and the clinician’s assessment and plan. A useful admission H&P explains why the patient needs admission now, which findings support the working assessment, and what still needs to happen.

This guide focuses on adult general medical admissions. Start with the blank H&P template or the completed fictional example. Clinical decisions in the example are supplied as part of the scenario; the exercise is about recording them accurately.

Sources checked: November 2, 2026. Physician review: pending.

Copyable history and physical template

Copy the blank prompts below or download the matching editable text file. Both contain the same fields, including separate examination and entry times, task owners and checkpoints, unassessed areas, and a saved-record agreement check. Keep assessed findings, unknown information and unfinished work distinguishable when adapting them to your hospital’s admission note.

For an alternative layout, the admission H&P template library offers a different admission template in Word and text formats. Use the prompts alongside the hospital’s medication, observation and order records. Copying those records in full into the narrative can make discrepancies harder to find.

Before writing, identify the patient and encounter, your role, the admitting service and the time you examined the patient. If documentation occurs later, retain both the examination time and entry time. An admission timestamp, a bedside assessment timestamp and an electronic signature timestamp describe different events.

Use a short source line: “History from patient at 14:25; clinic medication list dated October 20 reviewed; current dose discrepancy unresolved.” If a family member supplies information, preserve that attribution. The collateral-information guide shows how to keep differing accounts visible without assigning certainty to either one.

History, examination and assessment have different jobs

A clear H&P lets the next reader tell how each statement became known. Moving a statement into the wrong section can change its meaning: a patient’s denial of swelling is a history finding, while the examiner’s observation of no ankle edema belongs in the examination.

Scroll the table sideways on smaller screens.

The HPI should tell the current illness story. Background history explains relevant context. ROS records symptoms elicited by questioning. The examination records observed findings. Avoid repeating the same sentence in every section simply to fill the note.

A concise pertinent negative can be more useful than an unverified “all systems negative.” In HP-01, chest pain and hemoptysis were specifically asked about. The interview did not cover neurological, urinary or gastrointestinal symptoms. Use the review-of-systems question bank to plan the interview, then document the answers actually obtained.

Build an admission story from the available evidence

Start with the change that brought the patient to hospital. Connect onset and progression to baseline function, prior evaluation, treatment received and response. Then explain the admission decision. “Admit for pneumonia” names a working diagnosis but omits the reason outpatient management is insufficient in this particular assessment.

In the example, the clinician identifies a new oxygen requirement and a need for monitoring and initial treatment. The note preserves the two saturation measurements with their oxygen context. Calling the later value “normal on room air” would remove a key part of the admission rationale. A timed vital-signs record can support the narrative without collapsing the trend into one number.

Medication history needs a separate verification process. AHRQ’s MATCH toolkit describes a shared medication list, defined responsibilities and updates when more reliable information becomes available. Check the patient’s current use against older prescriptions when reconciling the list. AHRQ medication-reconciliation process

For each discrepancy, retain the competing sources, what is still unknown, and who will resolve it. Record actual home use separately from inpatient prescribing and administration. Record the reported allergy reaction and flag any details that need clarification. The medical-history form guide has questions patients can use to prepare their history.

For the assessment and plan, use a repeatable sequence:

1. Name the problem and the degree of certainty.
2. Connect the interpretation to specific evidence.
3. Identify meaningful alternatives or missing information.
4. Record the clinician’s selected action and rationale.
5. State what is ordered, completed, pending or reviewed.
6. Assign remaining work to a person and an agreed checkpoint.

HP-01: from source facts to an admission note

HP-01 is an original fictional adult-admission exercise. Alex Morgan and the clinicians below are invented. The observations, decisions and review checkpoints are supplied for this case; they are not universal treatment instructions or a tested hospital workflow.

Source packet

Alex is 62 and is admitted to the medical ward on November 2, 2026, at 14:20. Dr. Reed interviews and examines Alex at 14:25 and authenticates the admission note at 14:45. The record available for this exercise closes at 14:40.

• Patient history: three days of productive cough with yellow sputum and feeling feverish; breathlessness worsened over the past 24 hours. Alex denies chest pain and hemoptysis when asked. Baseline function is independent, including stairs; no home oxygen use. Alex lives with a partner.
• Background: Alex reports hypertension, appendectomy at age 25 and no known chronic lung disease. Mother has hypertension. Alex reports never smoking, one or two glasses of wine weekly and no other substance use. Other background information is unavailable; no other ROS questions were asked during this interview.
• Medication and allergy history: Alex reports amlodipine 5 mg orally daily, last taken yesterday. The clinic list dated October 20 says 10 mg daily. Alex reports hives after amoxicillin in childhood; further reaction details are unavailable.
• Observation record: at 14:05, oral temperature 38.1°C, heart rate 104/min, blood pressure 128/76 mmHg, respiratory rate 24/min and SpO₂ 90% on room air. RN Casey records oxygen started at 14:10 under the ED order, at 2 L/min by nasal cannula. SpO₂ is 94% on that support at 14:20.
• Examination: Dr. Reed finds Alex awake and conversant, with increased respiratory effort and left basal crackles. Heart rhythm is regular; abdomen is soft and nontender; no ankle edema is observed. No additional examination findings are supplied.
• Investigations: the 14:15 chest radiograph report describes left basal opacity, possibly infection or atelectasis. The 14:15 laboratory report gives WBC 13.2 × 10⁹/L and creatinine 0.9 mg/dL. Respiratory viral PCR was collected at 14:10 and remains pending at 14:40.
• Clinician’s decisions: Dr. Reed assesses probable pneumonia with acute hypoxemia and selects admission for the new oxygen requirement, monitoring and initial treatment. A prescriber-selected antimicrobial order, HP-O1, is entered at 14:35; administration has not been recorded. Monitoring, diet, mobility and prevention decisions are documented separately in admission order record HP-O2. No specific regimen is supplied in this teaching packet.
• Ownership: Casey accepts reassessment at 15:00; Reed will review at 15:15 and check PCR at 16:00. Earlier deterioration uses the unit’s urgent-response route. Pharmacist Taylor accepts medication verification by 17:00, with Reed responsible for the subsequent prescribing decision. Reed will clarify the reported allergy reaction, complete the resuscitation-preference discussion, verify its order and review immediate support needs at 15:15. Unavailable results or unresolved tasks must be handed over with acceptance.

Finished admission H&P

Patient / encounter: Alex Morgan, 62; HP-01, adult medical ward. Admitted November 2 at 14:20. Interview and examination 14:25; entry authenticated by Dr. Reed at 14:45, using information available through 14:40.

Sources: patient, ED observations and order record, current investigation reports, and October 20 clinic medication list. Medication discrepancy and further allergy details remain unresolved.

Chief concern and HPI: productive cough for three days with subjective fever and worsening breathlessness over the past day. Yellow sputum reported. Denies chest pain and hemoptysis when asked. Usually independent with stairs and does not use home oxygen. ED saturation was 90% on room air at 14:05; oxygen commenced at 14:10 under the ED order, with saturation 94% on 2 L/min nasal cannula at 14:20.

Background: patient reports hypertension and appendectomy at 25; no known chronic lung disease. Lives with partner. Mother has hypertension. Never smoked; reports one or two glasses of wine weekly and no other substance use. Amlodipine reportedly 5 mg orally daily, last dose yesterday; October 20 list records 10 mg. Current dose not yet reconciled. Reports childhood hives with amoxicillin; additional reaction details unavailable.

ROS: respiratory and constitutional symptoms as above; chest pain and hemoptysis denied. Other systems were not assessed in the supplied interview.

Examination and observations: Dr. Reed, 14:25: awake and conversant, increased respiratory effort, left basal crackles, regular heart rhythm, soft nontender abdomen and no ankle edema. No additional examination findings recorded. At 14:05: oral temperature 38.1°C, HR 104/min, BP 128/76 mmHg, RR 24/min. Oxygen measurements and support are recorded in the HPI.

Data: 14:15 radiograph report: left basal opacity, infection versus atelectasis. WBC 13.2 × 10⁹/L; creatinine 0.9 mg/dL at 14:15. Viral PCR collected 14:10, pending at 14:40.

Assessment and plan:

1. Probable pneumonia with acute hypoxemia. Feverish illness, productive cough, focal crackles and opacity support the working assessment; the report also considers atelectasis, and an organism is unconfirmed. Admit for new oxygen requirement, monitoring and initial treatment. Antimicrobial order HP-O1 entered at 14:35; administration not recorded as of 14:40. Refer to active orders for the selected regimen and monitoring. Casey will reassess at 15:00; Reed will review at 15:15, with earlier urgent escalation for deterioration under the unit pathway. Reed will review PCR at 16:00 and arrange accepted handover if still pending.
2. Medication-history discrepancy in reported hypertension treatment. Reported home dose is 5 mg; the October 20 list records 10 mg. Medication dose remains unverified. Taylor has accepted verification by 17:00; Reed will make the prescribing decision after review. Reed will seek further details of the reported amoxicillin reaction at 15:15; retain the reported allergy and hand over any remaining uncertainty.
3. Admission coordination. See HP-O2 for the separately documented admission-order decisions. Resuscitation preferences and the corresponding order await confirmation. Reed will discuss the preferences and verify the order at 15:15. New oxygen need is an immediate discharge barrier; Reed will review immediate support needs at 15:15 and update coordination as the clinical course develops.

Orders and follow-up

The note references HP-O1 for the antimicrobial order. Check that the linked order contains the selected medication, dose, route and frequency. For HP-O2, check the individual admission orders and their authentication; an “admission orders done” checkbox leaves those details out.

At signing, PCR review and medication verification are still pending, with Reed and Taylor responsible for the next steps. Keep those tasks open until the work is completed or another team member accepts responsibility.

Update the record without rewriting admission history

Continue HP-01 with this additional fictional information: at 16:50, Taylor contacts the community pharmacy, which confirms a 5 mg prescription issued October 25 that superseded the older 10 mg prescription. Alex confirms taking 5 mg. At 17:00, Reed reviews that evidence, reconciles the home-medication list to 5 mg daily and records the inpatient prescribing decision in the order record.

A suitable update is:

November 2, 17:00 — Dr. Reed. Taylor’s 16:50 pharmacy verification and patient confirmation resolve the admission amlodipine discrepancy: current home use is 5 mg orally daily; the October 20 list was superseded by the October 25 prescription. Home-medication list reconciled. Inpatient prescribing decision recorded separately in the medication orders. Verification task closed.

Keep the unresolved discrepancy in the original 14:40 account and the verified dose in the 17:00 update. Medication administration, PCR review and the resuscitation-preference discussion each need a separate entry when completed.

Before handoff, compare the narrative, home-medication list, active orders and outstanding-task list. If only the paragraph changed, the next clinician may still encounter a conflicting structured field. The medical charting software guide explores that distinction.

Practice: repair an inaccurate admission draft

Using only the source packet available through 14:40, review this draft:

Oxygen saturation normal on room air. No known allergies. Amlodipine 10 mg confirmed. Antibiotics given; viral PCR negative. Full examination normal apart from crackles.

Identify the unsupported claims before opening the answer. Do not use the 16:50 pharmacy call to repair a note describing the earlier assessment.

Reveal the HP-01 draft review

Revised excerpt: SpO₂ was 90% on room air at 14:05 and 94% on 2 L/min nasal cannula at 14:20. Alex reports childhood hives with amoxicillin; further details are unavailable. Amlodipine dose is unresolved between patient-reported 5 mg and the October 20 list’s 10 mg; Taylor will verify the dose by 17:00, with Reed responsible for prescribing review. Antimicrobial order entered at 14:35; administration not recorded by 14:40. Viral PCR remains pending. Record the supplied examination findings individually; no additional examination findings are available.

• The later oxygen value was measured on supplemental oxygen.
• Keep the reported amoxicillin reaction in the allergy history while seeking further details.
• The older medication list was not verified as current.
• Check the medication administration record for evidence that the dose was given.
• Keep the PCR marked pending until a result is available.
• A partial examination cannot support “full examination normal.”

Timing and setting change the requirements

For U.S. Medicare-participating hospitals governed by 42 CFR 482.24, the H&P generally must be completed within 30 days before or 24 hours after admission or registration, and before surgery or a procedure requiring anesthesia. A pre-admission H&P within that window requires an updated examination within 24 hours after arrival and before the procedure. The regulation includes a policy-based exception for specified outpatient procedures; it is not a general inpatient exemption. Entries also require dating, timing and authentication. 42 CFR 482.24

The Joint Commission explains that the update addresses changes since the earlier H&P and that the post-arrival clock starts when the patient physically arrives for admission or registration. An H&P older than 30 days cannot simply be updated to meet that rule. Joint Commission H&P timing FAQ

For example, a November 1 H&P followed by a November 2 admission requires the applicable update assessment. Keep the original document date and record the new examination, assessment of changes, responsible clinician and time through the hospital’s update process.

Before adopting a template, confirm the service’s content requirements, authorized authors, supervision or co-signature rules, and location of the admission record. Adult medical admission, elective surgery, obstetric admission and pediatric admission are different documentation contexts. Institutions outside the United States use their own applicable requirements.

Do not expand the note simply to generate more billing text. CMS explains that medical necessity and the applicable E/M selection method govern payment; for most visit families, level selection uses medical decision-making or time. CMS E/M documentation guidance

Admission history and physical quality checklist

Review the saved record, not only the draft on screen:

• Correct encounter: patient, service, admission time, examination time and entry time agree.
• Traceable history: the patient’s account, collateral information and dated records remain distinguishable.
• Relevant chronology: the note explains baseline, change, ED course and the clinician’s reason for admission.
• Honest examination: findings were actually assessed; observation units and oxygen context remain attached.
• Reasoned assessment: evidence supports the stated certainty, alternatives and admission plan.
• Orders, treatment and results: distinguish what was reported, ordered, administered or reviewed.
• Follow-up responsibilities: every pending result, discrepancy or incomplete discussion has an owner and checkpoint, with accepted handover when needed.
• Check the saved records: narrative, structured fields, active orders and task records agree; later updates retain their dates.
• Accountable entry: authentication and required supervisory review follow the hospital’s process.

Use the medical-charting practice cases to rehearse these checks. As care progresses, retain the admission baseline and add the actual response, decisions and follow-up. That chronology gives the eventual discharge summary a reliable starting point.

For AI-assisted drafting, see Vero’s history and physical notes workflow. Review the draft against the encounter information and your organization’s requirements before adding it to the record.