Writing a History and Physical

Writing a History and Physical

By Jeffrey L. Greenwald, MD, Assistant Professor of Medicine, Division of General Internal Medicine, Boston Medical Center, Boston, MA.


1. Source
2. Chief Complaint (CC)
3. History of the Present Illness (HPI)
4. Past Medical History (PMH)
5. Medications (Meds)
6. Allergies (All)
7. Family History (FHx)
8. Social History (SHx)
9. Review of Systems (ROS)
10. Physical Exam (PE)
11. Laboratories/Data
12. Assessment/Impression/Summary
13. The Plan
14. Problem List
15. Organ System Approach
16. Writing a History and Physical: The Abridged Guide
17. Writing a Daily Progress