History and physical: what each part means and how to test it against the chart

A history and physical, usually shortened to H&P, is the complete first assessment of a patient by a physician or another qualified clinician. It is written on admission to hospital, before surgery, and at the start of care in many other settings. CMS describes its purpose as finding anything in the patient's condition that would affect the planned treatment, such as a medication allergy or a condition that needs extra precautions.

The H&P has 2 halves. The history is what the patient, family or old records report: symptoms, past illnesses, medications, allergies, family and social history. The physical is what the clinician examined. The assessment and plan pull them together into a working diagnosis and next steps.

For a reviewer, the H&P sets the baseline. It is the first place to look for what was known at admission, and the document later notes tend to copy from. It is also a document where templates and copied text are common, so each statement in it deserves the question: was this asked, examined and found, or was it filled in?

Terms you will meet

Chief complaint (CC)

The reason for the visit, often in the patient's words.

History of present illness (HPI)

The story of the current problem: onset, course, severity, what makes it better or worse.

PMH, PSH

Past medical and past surgical history.

Review of systems (ROS)

A checklist of symptoms by body system. "14-point ROS negative" means 14 systems were reported as asked about and negative.

Physical exam (PE)

Findings by system: vital signs, general appearance, heart, lungs, abdomen, neurologic and so on.

Assessment and plan (A/P)

The clinician's diagnosis or differential and what will be done.

Update note

A short entry confirming or updating an H&P done before admission. Required within 24 hours and before surgery.

Pertinent negative

A symptom or finding specifically looked for and absent. It matters when the absence is later disputed.

The mock H&P below was written before a planned knee replacement. The layout is invented; every hospital's template differs. The 9 marked parts appear in almost every H&P.

What to check each section against

Electronic records made the H&P faster to write. Templates fill in a normal review of systems and a normal exam with 1 click; earlier notes can be copied forward; results and lists import automatically. A 2014 review in Chest describes the risks: unclear authorship, outdated information carried forward, and notes that no longer show what was actually done.

How much of a note is original? A UCSF study of inpatient progress notes found that in a typical note, 18% of the text was typed by the author, 46% was copied and 36% was imported. Progress notes are not H&Ps, but the same tools write both.

How much of a documented exam happened? Berdahl and colleagues sent trained observers into 180 emergency department encounters and compared what they saw and heard with what the residents documented:

None of this means a templated note is false. It means a line like "14-point ROS negative" or "heart: regular rate and rhythm" is weak evidence on its own. When a case depends on what was asked or found at admission, it should be tested against notes written independently on the same day, such as nursing assessments, triage notes and specialist notes.

The federal hospital rules set when an H&P must be done, who may do it and when an update is required. The same timing appears in 3 places: the medical staff bylaws rule, the medical records rule and the surgical services rule.

CMS guidance adds 3 points that matter in review. An H&P can be split among several practitioners, and the one who authenticates it is responsible for its contents. A pre-admission H&P can come from the patient's own doctor, which is how outside documents enter the hospital chart. And timing is judged against the procedure:

"An H&P that is completed within 24 hours of the patient's admission or registration, but after the surgical procedure, procedure requiring anesthesia, or other procedure requiring an H&P would not be in compliance with this requirement."

The update note

When the H&P was done before admission, the update note is the hospital's own check. CMS says the update must document an examination for any changes that might matter for the planned treatment. If there are none, the practitioner may record that the H&P was reviewed, the patient examined and "no change" found. A "no change" update written when other notes show a change is a common finding. Our guides to altered medical records and EHR audit trails cover how to test when an update was actually written.

The medication list in the H&P is what admission orders are built from, and it is wrong often. Tam and colleagues reviewed 22 studies with 3,755 patients comparing physicians' admission medication histories with comprehensive ones. Errors occurred in up to 67% of cases: 10% to 61% of patients had at least 1 drug left off, and 13% to 22% had a drug added that they were not taking. In the studies that judged severity, 11% to 59% of the errors were clinically important.

That is why nursing and pharmacy medication reconciliation exists, and why the reconciliation and the H&P should be read together. When they disagree, the question is which list the orders followed.

For the drugs actually given, the medication administration record guide shows how to line up orders, the MAR and the H&P. For daily notes that copy from the H&P, see the SOAP note guide.

What each flag means

1. A baseline that aged. The 05/20 H&P was within the 30-day window, but a new diagnosis and a new drug came 8 days later. That is what the update note exists to catch.
2. The drug was in the chart before surgery. Nursing recorded the anticoagulant and its last dose at 06:20. Whether the surgical and anesthesia teams saw it is in their notes, orders and the audit trail.
3. A contradicted exam. The pre-op nurse recorded an irregular pulse 15 minutes before anesthesia. The H&P says regular rhythm; the update says no change.
4. An update written after the procedure started. Signed at 09:40, more than 2 hours after anesthesia start. Under CMS guidance, that timing does not comply. The audit trail shows whether it was written then or only signed then.
5. The response to swelling. The time from the 22:10 nursing note to the first physician note and the return to the operating room belongs on the timeline too.

The same case on 1 timeline

The method works for an admission H&P, a pre-operative H&P or a clinic intake. Start with the dates, then test the content.

1. Fix the times. H&P date and signature, admission time, update time, anesthesia or procedure start.
2. Check the window. No more than 30 days before admission, and the update within 24 hours and before the procedure.
3. Identify the authors. Who performed, who documented, who authenticated. The authenticator is responsible.
4. Compare the medication list. Against nursing reconciliation, pharmacy records and the first orders.
5. Compare the allergies. Against nursing intake and the pharmacy profile.
6. Test the templated findings. ROS and exam against same-day nursing, triage and specialist notes.
7. Look for copied text. Identical wording or old values from a prior admission or visit.
8. Look for what happened between. Diagnoses, drugs and results between the H&P and the procedure, and whether the update mentions them.

Can this H&P be relied on as the baseline?

HISTORY AND PHYSICAL
Patient: [NAME / ID]    Date/time: [ ]
Setting: [admission / pre-op / clinic]   Planned procedure: [ ]
Source of history: [patient / family / records]

Chief complaint: [ ]
HPI: [onset, course, severity, modifiers, prior treatment]
PMH: [ ]          PSH: [ ]
Medications (name, dose, frequency, LAST DOSE): [ ]
  Anticoagulants / antiplatelets: [ ]
Allergies (reaction): [ ]
Family history: [ ]   Social history: [ ]
ROS: [list systems actually asked; positives and pertinent negatives]

Exam: Vitals [ ]
  General [ ] HEENT [ ] Heart [ ] Lungs [ ]
  Abdomen [ ] Extremities [ ] Neuro [ ] Focused: [ ]
Results reviewed: [labs, ECG, imaging with dates]

Assessment: [ ]
Plan: [ ]   Fit for procedure: [yes / no / conditions]

Author: [NAME, ROLE]   Signed: [DATE, TIME]

UPDATE NOTE (if H&P done before admission)
H&P dated [ ] reviewed. Patient examined [DATE, TIME].
Changes since H&P: [none / list]   Signed: [NAME, DATE, TIME]

H&P CROSS-CHECK
Patient: [ID]   H&P date: [ ]   Update: [ ]
Admission: [ ]   Procedure start: [ ]

Section | H&P says (page) | Other source says (page)
  | Match? | Question

Examples:
Meds | lisinopril, metformin (p. 4)
     | + anticoagulant, last dose 06/14 20:00 (p. 20)
     | No | Held? Who knew?
Exam | heart regular (p. 5)
     | irregular pulse 96, 06/15 07:15 (p. 21)
     | No | Update says no change (p. 7)
Timing | update signed 06/15 09:40 (p. 7)
       | anesthesia start 07:30 (p. 24)
       | No | After the procedure began

Before you rely on an H&P

• The H&P and every update are in handIncluding any outside, pre-admission H&P.
• Admission and procedure times are knownFrom registration and the anesthesia record.
• The nursing medication reconciliation is in handWith last-dose times.
• Same-day nursing and triage notes are in handTo test the ROS and exam.
• Notes between the H&P and the procedure are in handSpecialist visits, new prescriptions, results.
• The audit trail is requested if timing is disputedFor when the H&P and update were written and signed.

0 of 6 checked.

For surgical cases, the operative report guide covers the records written during and after the operation. For the end of the stay, see the discharge summary guide.

Chapter 7's method compares the H&P with every other note from the same days: nursing reconciliation, triage, specialist notes, the anesthesia record. In a surgical file that is hundreds of pages, and the contradicting line is often in a note nobody thought to read.

AI medical record review can pull every medication, allergy, diagnosis and exam finding from every note onto an AI medical chronology, each with a page-level citation, and show the H&P's version beside the others. An anticoagulant on the nursing list and absent from the H&P, or an irregular pulse 15 minutes before a "no change" update, becomes visible without reading every page in order.

The same caution applies as with any large language model (LLM). A model summarizing a chart will lean on the H&P because it is complete and well organized, and can repeat its templated normals as fact. Hallucination and omission are both risks, which is why every line needs its page and a human in the loop checks it. Whether a drug should have been held is a clinical judgment.

Medrecords AI works this way on the files you upload. It builds a cited medical chronology across the H&P, nursing, specialist and anesthesia records, each entry linked to its page. You can ask "every anticoagulant mentioned anywhere in the file, with dates and last-dose times" through cited Q&A, find conflicting findings with record search, surface statements of absence with negative findings detection, and flag records that should exist but were not produced. Flags are signals, not verdicts. It does not decide whether care met the standard, parse audit trails or retrieve records from providers. It runs under SOC 2 and HIPAA with a signed business associate agreement (see security and HIPAA). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license.

If you are comparing tools, our guide to medical record review covers what to ask any medical chronology software vendor. See how H&P review fits surgical error, medical malpractice, hospital risk management and expert witness work.

What is included in a history and physical?

Chief complaint, history of present illness, past medical and surgical history, medications and allergies, family and social history, review of systems, physical examination, results reviewed, and an assessment and plan, signed with date and time.

How long is an H&P valid before surgery?

Under federal hospital rules, an H&P done up to 30 days before admission can be used if an update note is completed within 24 hours after admission and before the surgery or procedure.

What is an H&P update note?

A short entry confirming the patient was re-examined and recording any changes since a pre-admission H&P. If nothing changed, CMS allows the practitioner to record that the H&P was reviewed, the patient examined and no change found.

Who can perform a history and physical?

A physician, an oral and maxillofacial surgeon, or another qualified licensed individual such as a nurse practitioner or physician assistant, as allowed by state law and hospital policy.

What does "14-point review of systems negative" mean?

That 14 body systems are recorded as asked about and negative. It is often generated by a template, so it should be tested against other notes from the same day.

Can copied text in an H&P be a problem in a lawsuit?

It can raise questions about what was actually current at the time. Identical wording or old values from an earlier visit are worth logging and comparing with independent notes.

What if the H&P was written after surgery?

CMS guidance says an H&P completed after the procedure does not meet the requirement, even if it is within 24 hours of admission. Emergencies are an exception.

Can AI compare an H&P with the rest of the chart?

It can extract medications, allergies and findings from every note and line them up with page citations so differences stand out. A clinician or expert decides what the differences mean.

Is it HIPAA compliant to upload hospital records to an AI tool?

It can be, with a vendor that signs a business associate agreement, holds a SOC 2 report and commits in writing not to train on your data. A consumer chatbot without a BAA is a different matter.

Regulations and the CMS State Operations Manual (Appendix A, revision 248) were read in full text from primary sources in September 2026, and quoted text is verbatim. Study figures come from the published abstracts and, for the 2017 research letter, the published text. The mock H&P, patient, physicians, dates and pages in chapters 2, 6 and 7 are hypothetical. Product facts come from this site's product pages. Nothing here is legal or medical advice.

• 42 CFR 482.22: medical staff bylaws, H&P timing and update requirements.
• 42 CFR 482.24: medical records content and authentication.
• 42 CFR 482.51: surgical services, H&P before surgery.
• CMS State Operations Manual, Appendix A: interpretive guidance at tags A-0358 and A-0359.
• Berdahl CT, Moran GJ, McBride O, et al., "Concordance between electronic clinical documentation and physicians' observed behavior", JAMA Network Open 2(9):e1911390, 2019.
• Wang MD, Khanna R, Najafi N, "Characterizing the source of text in electronic health record progress notes", JAMA Internal Medicine 177(8):1212-1213, 2017.
• Tam VC, Knowles SR, Cornish PL, et al., "Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review", CMAJ 173(5):510-515, 2005.
• Weis JM, Levy PC, "Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations", Chest 145(3):632-638, 2014.