Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:
History and Physical Note
Chief complaint/reason for admission/visit/consult.
HPI for the H&P or consult notes.
Medical, surgical, family, social, and allergy history.
Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
Vital signs and weight.
Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
Include a complete list of all diagnoses that are both acute and chronic.
List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
Discuss disposition and expected outcomes.
Identify and address health education, health promotion, and disease prevention.
Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
