The full form of H&P is History and Physical Examination

The History and Physical Exam, often called the “H&P” is the starting point of the patient’s “story” as to why they sought medical attention or are now receiving medical attention.

The History portion contains the chronology of what is wrong with the patient – often the “what is wrong with the patient” is called the “chief complaint” and is often abbreviated “CC” in the History documentation in the medical record. For example, a patient may report that there is blood in her sputum and this has been present for a period of one week. The physician will often write: CC: “Patient reports blood in sputum for a period of one week.”

Following the chief complaint, the physician will also document any other pertinent History about the patient’s medical, behavioral, and psycho-social aspects.

Following the History, the physician SHOULD then perform a Physical Exam (or “PE”). The Physical Exam includes both objective and subjective assessments of the patient’s physical being. Documentation of the Physical Exam is typically grouped by body system, such as Head, Eyes, Ears, Nose and Throat (often abbreviated “HEENT”), Respiratory, Genito-Urinary, etc. Objective medical measurements such as blood pressure, pulse rate, temperature, etc. are made and documented. There are also many subjective measurements made during the PE, such as visual observation and palpation, often with “best judgment” assessments as to size, location, and involvement of any abnormal finding.