The history and physical, usually shortened to H&P, is one of the first documents every clinician learns to write. It is the comprehensive note created when a patient is admitted to the hospital or seen for a full initial evaluation, and it sets the foundation for everything that follows. For medical students, residents, and other trainees, learning to write a clear H&P is a core clinical skill.
This guide walks through what an H&P is, when it is used, and each of its components, with practical tips for writing one that is organized and useful. It is intended for education and documentation support. It is not medical advice, and it does not replace the clinical training, supervision, or institutional templates that guide real patient care.
An H&P is a structured clinical document that captures a complete picture of a patient at a single point in time. It records the story of why the patient is seeking care, the relevant background, a head to toe examination, and the clinician's initial assessment and plan.
Unlike a brief progress note that tracks one day of a hospital stay, the H&P is broad. It is meant to gather enough information for any member of the care team to understand the patient's situation and reasoning behind the initial plan. Because it is comprehensive, it is usually the longest note in the chart.
The H&P appears at moments that call for a full evaluation rather than a focused update. Common examples include:
After the H&P is complete, shorter daily notes usually take over. Many of those follow the SOAP format, which we cover in our complete guide to SOAP notes.
Templates vary by institution, but nearly every H&P contains the same building blocks. Understanding what belongs in each one is the key to writing efficiently.
The chief complaint is a short statement, often in the patient's own words, describing the main reason for the visit. It is usually one line, such as chest pain for two hours. It sets the frame for the rest of the note.
The history of present illness, or HPI, is the narrative heart of the H&P. It tells the story of the current problem in a clear timeline. A widely taught way to make sure the story is complete is the OLDCARTS approach, which prompts you to describe:
A strong HPI reads like a coherent story, not a list of disconnected facts.
This part of the note collects the background that shapes clinical decisions. It generally includes:
The review of systems, or ROS, is a checklist style survey of each body system to catch symptoms the patient may not have mentioned. It is documented separately from the HPI and helps confirm what is present and what is absent. Even when many systems are negative, recording them shows that the question was asked.
The physical examination records objective findings from vital signs through a system by system exam. Documentation is typically organized by region or system, such as general appearance, cardiovascular, respiratory, abdominal, neurologic, and so on. For a plain language overview of what a general physical exam involves, the MedlinePlus Medical Encyclopedia entry on the physical examination is a helpful reference. Describe what you find in specific terms rather than relying only on labels like normal.
The assessment and plan is where clinical reasoning becomes visible. The assessment summarizes the clinician's interpretation, often including a differential diagnosis for the main problem. The plan then lays out next steps, frequently organized problem by problem, covering tests, treatments, consults, and monitoring. This section is where the note stops describing and starts directing care.
Students often ask how the H&P differs from a SOAP note. The simplest way to think about it is scope. The H&P is the comprehensive first look, gathering a full history and complete exam. The SOAP note is the focused follow up that tracks how a known problem is changing from one encounter to the next.
The two formats share DNA. Both move from the patient's story to objective findings to assessment and plan. Once you can write a thorough H&P, adapting to the shorter SOAP structure is straightforward.
Most H&Ps today are written inside an electronic health record, which brings both help and hazard. Templates, saved phrases, and pull in tools can save real time, but they also make it easy to carry forward information that no longer fits the patient in front of you.
Two habits keep an electronic H&P trustworthy. First, review anything that is automatically populated and confirm it is accurate for this encounter. Second, make sure the parts that require your own reasoning, especially the history of present illness and the assessment, are written fresh rather than copied. An efficient note still has to be a true one.
The following is a brief, hypothetical skeleton to show how the sections flow. It does not describe a real patient and contains no protected health information.
Even in skeleton form, the note moves logically from story to data to reasoning to action.
These habits help trainees produce notes that attendings and teammates can trust:
A comprehensive note takes time to write, and documentation is a well known contributor to clinician workload. AI documentation tools can ease that burden by drafting parts of the note from the encounter so the clinician can review and complete it rather than start from a blank screen.
An AI medical scribe such as DocuMed AI can help organize the narrative and structure findings into a draft, which the clinician then edits and signs. The tool supports documentation and does not make clinical decisions or replace clinical judgment. To understand the approach, see how it works, our overview of an AI SOAP note generator, and how AI for EHR documentation reduces charting time. If you are comparing options, our guide to the best AI medical scribe outlines what to look for.
For trainees, a draft can also be a learning aid rather than a shortcut. Comparing a structured draft against your own note can highlight the sections you tend to leave thin, such as a differential in the assessment or the specifics of the plan. The responsibility to think through the case and verify every detail always stays with the clinician.
H&P stands for history and physical. It is the comprehensive clinical note that documents a patient's history, a physical examination, and the clinician's initial assessment and plan, typically at admission or a first full evaluation.
An H&P is a complete initial evaluation with a full history and exam. A progress note is a shorter, focused update on a known problem during ongoing care. The H&P sets the baseline, and progress notes track change over time.
The history of present illness is the narrative that describes the current problem in a clear timeline. Frameworks such as OLDCARTS help ensure the story covers onset, location, duration, character, aggravating and alleviating factors, radiation, timing, and severity.
Long enough to be complete and no longer. Because it is comprehensive, an H&P is usually the longest note in the chart, but every section should still earn its place. Clarity and organization matter more than raw length.
An AI scribe can draft portions of an H&P from the encounter so the clinician can review, correct, and finalize it. The clinician remains responsible for accuracy and for all clinical decisions, and any tool used with patient information should meet appropriate privacy and security standards.
The review of systems is a structured survey of each body system, documented separately from the history of present illness. It captures symptoms the patient may not have volunteered and records both positive findings and pertinent negatives, which helps show that the questions were asked.
The H&P is where clinical documentation begins. Master the flow from chief complaint to HPI to history, exam, and a reasoned assessment and plan, and you will have a structure you can rely on throughout training and practice. Focus on a clear story, honest objective findings, and a plan organized by problem.
If writing comprehensive notes is eating into your day, DocuMed AI can draft the documentation so you can review instead of type. Book a demo to see how it fits into your workflow.
This article is for educational and documentation support purposes only. It is not medical advice. Clinicians remain responsible for their documentation and for all clinical decisions, and should follow their institution's policies and templates.
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