Clinical H&P Template v4

Chief Complaint (CC)

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Chief complaint — in patient's own words

History of Present Illness (HPI)

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HPI Mnemonics

OOnset — when/how did it start? LLocation — where? Radiation? DDuration — how long does it last? CCharacter — sharp, dull, burning, pressure… AAggravating / Alleviating factors RRadiation — does it travel? TTiming — constant or intermittent? SSeverity — pain scale 0–10

Quick scaffold:

HPI Narrative

Medications

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Medication	Dose	Frequency	Route	Indication

Allergies (include reaction type)

Past Medical History (PMH)

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Medical conditions (include dates if known)

Surgical / hospitalization history

OB history (if applicable)

Family History (FH)

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First-degree relatives — conditions, age of onset, living/deceased

Social History (SH)

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Tobacco

Alcohol

Recreational Drugs

Occupation

Living situation

Marital status

Exercise

Diet

Other (travel, exposures, stressors, support system, cultural considerations)

Review of Systems (ROS)

Mark each system▲

Vital Signs

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BP Sys

mmHg

Normal: 90–129

BP Dia

mmHg

Normal: 60–84

bpm

Normal: 60–100

br/min

Normal: 12–20

Temp

°F

Normal: 97–99.5

SpO₂

Normal: ≥95%

Height

ft/in

Weight

lbs

BMI

—

Pain Scale (0–10)

NoneModerateSevere

Other vitals / monitoring

Physical Examination

Tap findings to select · green = normal · red = abnormal▲

Neurological Examination

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Mental status

Cranial Nerves

CN	Test	Intact	Notes

Motor strength (0–5)

Group	R	L

0=absent · 1=trace · 2=no gravity · 3=vs gravity · 4=vs resistance · 5=full

Deep tendon reflexes (0–4+)

Reflex	R	L

0=absent · 1+=dim · 2+=normal · 3+=brisk · 4+=clonus

Sensory

Cerebellar / Gait

Labs & Diagnostics

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Laboratory results

Imaging / other diagnostics

Clinical calculator results (auto-filled from Calculators tab)

Assessment

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Primary / working diagnosis

Differential diagnoses (order by likelihood)

Clinical reasoning / summary

Problem List & Plan

One plan per problem▲

General Plan

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Diagnostic workup ordered

Medication changes

Referrals / consults

Follow-up

Patient education & counseling

Glasgow Coma Scale (GCS)

Altered consciousness / TBI▲

GCS Total

Mild / Normal

13–15: Mild impairment or normal. Monitor closely.

Eyes (E)

Verbal (V)

Motor (M)

CURB-65 (Pneumonia Severity)

Guides admission decision▲

CURB-65

Low Risk

Score 0–1: Low mortality. Treat as outpatient if clinically appropriate.

C — Confusion (new disorientation to person, place, or time)+1

U — Urea/BUN >19 mg/dL+1

R — Respiratory rate ≥30 breaths/min+1

B — BP: systolic <90 mmHg or diastolic ≤60 mmHg+1

65 — Age ≥65 years+1

Wells PE Score

Pre-test probability of pulmonary embolism▲

Wells PE

PE Unlikely

≤4: PE unlikely. Order D-dimer; if negative, PE excluded.

Clinical signs/symptoms of DVT (calf tenderness, swelling)+3

PE is #1 diagnosis or equally likely as alternative diagnosis+3

Heart rate >100 bpm+1.5

Immobilization (≥3 days bedrest) or surgery in the previous 4 weeks+1.5

Previous objectively diagnosed DVT or PE+1.5

Hemoptysis+1

Malignancy (on treatment, treated in last 6 months, or palliative)+1

PHQ-9 (Depression Screening)

Over the last 2 weeks…▲

PHQ-9

Minimal / None

0–4: Minimal depression. Watchful waiting.

0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling/staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure

7. Trouble concentrating on things

8. Moving/speaking slowly (or being fidgety/restless)

9. Thoughts that you would be better off dead or hurting yourself

How difficult have these made it to do your work, take care of things at home, or get along with other people?

GAD-7 (Anxiety Screening)

Over the last 2 weeks…▲

GAD-7

Minimal / None

0–4: Minimal anxiety. Monitor, reassess PRN.

0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it's hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen

Patient Encounter Log

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