History and physical (H&P)

Setting: Inpatient / outpatient

CHIEF COMPLAINT:
[Reason for visit in the patient's words]

HISTORY OF PRESENT ILLNESS:
[Onset, location, duration, character, aggravating/relieving factors, associated symptoms]

PAST MEDICAL / SURGICAL HISTORY:
[List]

MEDICATIONS / ALLERGIES:
[Reconciled list; allergies and reactions]

SOCIAL / FAMILY HISTORY:
[Pertinent items]

REVIEW OF SYSTEMS:
[Pertinent positives and negatives]

PHYSICAL EXAM:
Vitals: [BP, HR, RR, Temp, SpO2, Wt]
[System-based findings]

DATA:
[Labs, imaging, other results]

ASSESSMENT:
[Summary statement and clinical reasoning]

PLAN:
1. [Problem] - [plan]
2. [Problem] - [plan]