Here is an example of a hospitalist H&P in abbreviated template form. If you understand this history and physical format, you have definitely been in nursing or medicine for a very long time. Or you've got Savant syndrome. Probably both though. If any important details have been left out, leave your abbreviations in the comments below and they'll get added to the story. The goal here is to make this the most abbreviated hospitalist H&P in history.
HPI: RUQ 12/10 ABD x 2 HRS. 4/10 W/ 2 MG MSO4
ALL: NKDA
RX: ASA, FeSO4, HCTZ, MOM, NTG, TMP/SMX, MTX, MVI, APAP
PMH: CAD, 5VCABG, HTN, HLP, COPD, OSA-CPAP/O2, TIA, CVA, CHF, PVD, IBS, DM, GAD, OA, OP, AF, AICD, UTI, RA, SAH, SDH, UGIB, LGIB, NPH, FTT, TAH-BSO, BTKA, BTHA, T&A,
SH: NS, ND, DNR
FH: NC
ROS: 10 PT ROS (-)
PE:
CONST: VSS AF WF, NAD
HEENT: AT/NC, MMM, PERRLA, EOMI
NCK: (-) JVD, (-) LAD
CV: RRR W/SYS M, PMI ND,
PLM: CTAB, (-) R/R/W
ABD: S/T/ND/BS (+), (-) HSM
MS: (-) C/C/E, NL ROM
NEU: , CN II-XII NL, NFD
SKN: NL
PSY: AOX3
LABS: WBC 13, HGB 13, INR 14 TB 13
CV: ECHO EF 55% PASP 35
EKG: NSR W/ NSTWI
RAD: U/S ABD W /CBD 13 MM
IMP: CDL
PLAN: NPO / FFP / F/U INR / ABX / GI 2 C +- ERCP / VTEP W/ SCDS.
RIP.
Ta dah!
"I've started documenting "see CT report" for my physical exam. Just so you know."
"Prepare yourself. Family history noncontributory means not done."
"I don't always do stat consults for need H&P. But when I do I wear my nonurgentologist hat."
"I don't always take a great history. But when I do, I have a don't ask don't tell policy."
By the way, this hospitalist H&P meets criteria for a level 3 hospital admission. How you ask? It has four HPI elements, at least one element each from past history, social history and family history and a 10 point review of systems. It meets criteria for the highest level physical examination with at least two bullet points each in nine different areas. Medical decision making is high complexity for numerous reasons. On the risk table, there is at least one acute medical conditions that poses a threat to life or bodily function (critical INR and choledocholithiasis) as well as high risk drug management with warfarin and four points under the diagnosis section of the Marshfield Clinic Audit Tool for at least one new problem with further workup planned.
This note is proof you don't have to write a novel to get paid for the work you are already providing. You just have to hope whomever audits the note recognizes all the abbreviations! The Happy Hospitalist Blog has a large collection of original, thoroughly researched, evaluation and management (E/M) lectures and CPT® lectures to decipher the complexities of medical billing and coding. A bedside E/M pocket reference card (seen and linked below) is also available for purchase to help you make sense of the American Medical-Industrial complex.
"Prepare yourself. Family history noncontributory means not done."
"I don't always do stat consults for need H&P. But when I do I wear my nonurgentologist hat."
"I don't always take a great history. But when I do, I have a don't ask don't tell policy."
)
By the way, this hospitalist H&P meets criteria for a level 3 hospital admission. How you ask? It has four HPI elements, at least one element each from past history, social history and family history and a 10 point review of systems. It meets criteria for the highest level physical examination with at least two bullet points each in nine different areas. Medical decision making is high complexity for numerous reasons. On the risk table, there is at least one acute medical conditions that poses a threat to life or bodily function (critical INR and choledocholithiasis) as well as high risk drug management with warfarin and four points under the diagnosis section of the Marshfield Clinic Audit Tool for at least one new problem with further workup planned.
This note is proof you don't have to write a novel to get paid for the work you are already providing. You just have to hope whomever audits the note recognizes all the abbreviations! The Happy Hospitalist Blog has a large collection of original, thoroughly researched, evaluation and management (E/M) lectures and CPT® lectures to decipher the complexities of medical billing and coding. A bedside E/M pocket reference card (seen and linked below) is also available for purchase to help you make sense of the American Medical-Industrial complex.
LINK TO E/M BEDSIDE POCKET CARD POST
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To finish off your Happy Hospitalist experience, here is a link to the most inclusive list of funny medical slang and acronyms you'll find anywhere on the internets!
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