Clinical Terminology : What is a History and Physical (H&P)?

Hi fellow CMIOs, CNIOs, Applied Clinical Informaticists, and other #HealthIT friends,

Today, I'm sharing more on the importance of terminology, in untangling and streamlining clinical workflows. 

In day-to-day healthcare, effective communication is the bedrock of success. Ensuring accurate and efficient communication in healthcare settings hinges on the use of standardized clinical terminology and documentation practices.

So to better understand the importance of standardized terminology in untangling and optimizing clinical workflows, we will look at one of the most common anchors of clinical workflow - the History and Physical (H&P). 

The History and Physical (H&P) is one of the first things medical students learn to perform in medical school. (Since around 1968, it's been generally written in the same structure as the SOAP note by Larry Weed, MD.) Asking ChatGPT40 for a summary on 11-10-2024, I got this :

A History and Physical (H&P) is a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider. This documentation is typically created at the time of a patient’s hospital admission, outpatient clinic visit, or before a surgical procedure. The purpose of the H&P is to provide a structured, thorough assessment of the patient’s health status, which helps guide diagnosis, treatment, and ongoing care.

The H&P typically includes the following elements:

1. Chief Complaint (CC): A brief statement summarizing why the patient is seeking care, often in the patient’s own words (e.g., “chest pain”).

2. History of Present Illness (HPI): A detailed description of the patient’s current symptoms or concerns, including onset, duration, characteristics, associated symptoms, and any factors that worsen or improve the condition.

3. Past Medical History (PMHx): Information about any prior illnesses, surgeries, hospitalizations, and chronic conditions, as well as any ongoing treatments or therapies.

4. Medication History: A list of current medications, including prescriptions, over-the-counter drugs, supplements, and dosages.

5. Allergies: Details of any known allergies to medications, foods, or other substances, along with reactions.

6. Family History: Information about the health of immediate family members to identify any genetic or hereditary conditions.

7. Social History: Insights into the patient’s lifestyle, including smoking, alcohol use, occupation, living situation, and exercise habits, which may impact their health.

8. Review of Systems (ROS): A systematic check of the patient’s body systems (e.g., cardiovascular, respiratory, gastrointestinal) to identify any other symptoms that may not have been initially reported.

9. Physical Examination: A head-to-toe assessment performed by the healthcare provider, covering major organ systems and noting findings like heart rate, lung sounds, and any abnormalities.

10. Assessment and Plan: Based on the gathered information, the provider lists diagnoses (or differential diagnoses) and outlines a plan for treatment or further evaluation.

The H&P is essential for creating a baseline of the patient’s health status, supporting diagnosis, guiding treatment, and facilitating communication among healthcare providers. In electronic medical records (EMRs), standardized templates often guide providers through completing these sections thoroughly and consistently.

While ChatGPT40 gives us a reasonable starting point that most medical professionals will quickly recognize, I'd like to add that it did not explicitly call out Surgical history (SurgHx), Psych history (PsychHx), or OBGYN History (OBGYNHx), which are often separately called out in certain H&Ps.

So in addition to the PMHx, PSurgHx, SocHx, PsychHx, and OBGYNHx, the foundations of Larry Weed's SOAP note can be found in most H&Ps : 

• SUBJECTIVE (S) = What is the patient telling you? (e.g. CC, HPI, ROS, etc.)
• OBJECTIVE (O) = What do you see? (e.g. Physical Exam, Vitals, Labs, Radiology, etc.)
• ASSESSMENT (A) = How do you interpret this, and what do you think the patient needs?
• PLAN (P) = What is your plan to address these issues?

While this gives us a helpful framework to start from - it doesn't really clarify the eleven (11) different types of H&Ps that are commonly used in healthcare. Let's start off our journey by looking at the first four : 

I want to call out these first four (4) H&Ps because they are sometimes confused in elective pre-operative (and pre-procedural) workflow discussions : 

1. Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That general pre-operative or pre-procedure H&P that is commonly done by a Surgeon, Proceduralist, or Primary Care Provider (e.g. Internal medicine, Family medicine, Geriatrics, Pediatrics, or OBGYN), which includes a pre-operative (or pre-procedure) risk evaluation and optimization plan.
2. Secondary (Focused) Specialist Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That secondary, focused pre-op or pre-procedure risk evaluation that might be needed for patients with complex histories, typically done by one or more specialist(s) at the request of the Surgeon, Proceduralist, or Primary Care Provider doing the Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation.
3. Interval H&P - That H&P where the Surgeon or Proceduralist briefly reviews, within 24h of surgery/procedure, the pre-operative H&P(s) - including the data elements PMHx, PSurgHx, FamHx, SocHx, Med List, Allergies, ROS, PE, and relevant labs and radiology -  and acknowledges that the information is all correct and accurate and that no changes or updates are needed prior to surgery/procedure, usually with a simple attestation : "I have read and reviewed the patient's pre-operative H&P and no changes or updates are required."  
4. Admission H&P - That H&P done by the Admitting Attending (or their clinical delegate) at the time of admission, usually to describe the patient's condition, reason(s) for admission, admission status, admitting team, admission active problem list and management plans, and contingency plans.  

While these contain many of the same data elements, they also contain different elements, and are authored by different provider(s) at different times. Mislabeling all of them as just "H&P" leaves potential room for confusion - For example, if post-operatively Inpatient Nurses seeking post-operative orders were to try to contact the PCP instead of the Surgeon, because the Pre-Op H&P and the Admission H&P are both labeled "H&P".

Similarly, distinguishing the Primary (General) Pre-Op H&P and Risk Evaluation from the Secondary (Specialist, focused) Pre-Operative H&P(s) is necessary to clarify who has the primary responsibility and what other specialist(s) might need to be involved in assessing a patient with a complex history (e.g. pulmonary, cardiac, renal, endocrine, or other complex medication, allergy, or anesthesia needs). Labeling both of these as an "H&P" just leaves room for confusing the two (e.g. a Surgeon sending the patient to a cardiac specialist for a primary risk evaluation.) 

If you have ever tried to create structured documentation, to encourage users to complete the data field(s) that are necessary and unique to each of these note types - You will quickly see why it's important to label each of these notes correctly. 

In short : Trying to 'keep it simple' by labeling them all as "H&P" only confuses users and makes it a challenge to structure your workflows. My advice : Call it what it is.

Just to be complete, I thought I'd share some of the other common types of H&Ps used across healthcare : 

These include : 

• 5. The Emergency Department (ED) H&P - That focused H&P that is commonly done by Emergency Medicine doctors, usually as part of their routine visits. (In some organizations, this is labeled an 'ED Progress Note.)
• 6. The Discharge Summary H&P - That H&P that is usually done by the Attending Provider (or their clinical delegate) at the time of discharge, to provide a synopsis of the patient’s hospital stay, covering the course of illness, treatments provided, and recommendations for follow-up. These also often include the admission reason, key findings, procedures done, discharge medications, patient's condition on discharge and instructions for aftercare, and they help enable a smooth handoff to outpatient providers to help ensure continuity of care and provide clear guidance for post-discharge recovery.
• 7. The Consultation H&P - That H&P that is often done by a specialist, either as part of an inpatient consult or an ambulatory referral, at the request of another provider seeking specialty evaluation.
• 8. The Annual Physical H&P - That H&P commonly done by a Primary Care Provider as part of an annual evaluation of a patient's overall health status and needs. These are often preventative in nature (rather than problem-focused) and usually cover the entire spectrum of a patient's health, including lifestyle factors, preventive screenings, immunizations, and a physical exam.
• 9. The Employee Physical H&P - That H&P commonly done by an Employee Health Provider as part of a pre-employment evaluation, fitness-for-duty evaluation, or workplace injury.
• 10. The Sports Physical H&P - That H&P commonly done by a Primary Care Provider, Cardiologist, or other Sports Medicine provider, to evaluate an athlete prior to playing competitive sports or engaging in other demanding physical exercise regimen.
• 11. The Insurance H&P - That H&P typically done by a Primary Care Provider or Insurance Provider to help evaluate a patient prior to completing agreements for an insurance policy.

... each of which also has unique authors and unique data elements for unique purposes - So if you want to structure these notes, they will also require unique (descriptive) names. 

IN CONCLUSION : 

Terminology is important. The accurate capture of H&Ps relies heavily on standardized clinical terminology. From admission to discharge, the use of consistent terms and codes across each H&P type ensures that information is unambiguous and interoperable within the healthcare system. Applied Clinical Informatics professionals play a crucial role here, by:

1. Creating Templates and Standardized Workflows: Clinical informatics teams often design templates that incorporate standardized terminologies, improving the quality and consistency of documentation across providers and specialties.

2. Supporting Clinical Decision Support (CDS): By ensuring that H&P documentation aligns with clinical terminology standards, CDS tools can better identify risk factors, suggest interventions, and flag potential issues based on coded data from H&Ps.

3. Optimizing for Billing and Compliance: The use of terminologies like ICD-10 and CPT in H&P documentation is vital for billing accuracy. Standardized language not only supports coding but also ensures compliance with regulations.

So my four key take-home messages for this post include : 

• There are at least eleven (11) H&Ps commonly used in healthcare - If you are a clinical provider, a medical records professional, a billing/coding person, or a clinical informaticist, it is helpful to familiarize yourself with all of them.  
• Many federal and state regulations only refer to them as an "H&P" - This, and the common saying "An H&P is an H&P..." potentially only causes confusion and workflow challenges.
• The right naming conventions / labeling can help you structure your documentation, and clarify and optimize your clinical workflows. 
• Remembering the mantra, "Call it what it is" will help you reduce confusion and untangle even your most complicated workflows.

For Clinical Informatics professionals, understanding these elements is critical to optimizing workflows, enhancing patient care, and contributing to the data-driven future of healthcare. By promoting accurate and standardized documentation, we can facilitate the development of a healthcare system that is not only more efficient but also more responsive to the needs of patients and providers alike.

I hope this helps you plan your document index and naming conventions, to help streamline your clinical processes. If you have any feedback or other comments, please leave them in the comments section below!

Have any experience with naming conventions for your clinical documentation? Feel free to share and leave other feedback in the comments section below. 

Remember, this blog is [ DRAFT ] guidance for discussion and educational purposes only - Your mileage may vary. Always check with your Clinical Leadership and your own Legal, Compliance, Regulatory, and Informatics leaders before adopting any definitions or new clinical standards.

Can we do better than SOAP?

So I've recently been looking at some of the most important standards we have, that few people appreciate. Some standards that I've recently been admiring the beauty of :

1. The 110-volt AC plug in America - Thank goodness for this! Imagine if you had to worry about which coffee maker you could or couldn't buy because it didn't have a plug that fit your house! (Or even better, think about how challenging it is to travel with that same coffee maker to a different country!)
2. Traffic lights - Thankfully, they all behave the same in our country. Imagine if driving from Maine to Florida meant having to learn different traffic signal patterns?
3. Traffic patterns - We all drive on the right side of the road in the U.S. - Imagine having to change as you drove state-to-state? (I wonder how they handle this in the Chunnel between France and England?)
4. Train tracks - Snopes.com has this interesting debunking about railroad gauge, that includes a mention of how during the American Civil War, the northern railroads had one gauge while southern railroads had multiple gauges -  this was argued by historian James McPherson to be one of the logistical factors that contributed to the Union army winning over the Confederate army. (And interestingly, after the North won the war, many of the southern railroads were rebuilt by the North, giving us the American standard of 4 feet, 8.5 inches.
5. The Apple iPhone/iPad/iPod charger - Although Apple toyed with some of the charging pins since the iPhone 3G, the plug has essentially been the same since the original iPod in 2001. Now it seems that since the iPhone 3G, you can use the same plug to charge your iPhone 3G, iPhone 4, iPhone 4S, iPad, iPad2, iPod Touch, and various other apple devices. I suspect this is why the plugs are becoming so ubiquitous that most of my friends now seem to have one in the kitchen just to let visitors charge their Apple devices.
6. American Standard Code for Information Interchange (ASCII) - This is arguably much larger than just an American standard - Although Unicode has expanded the ability for designing documents, ASCII is probably the most widely-used standard in computing.  Can you imagine if your processor didn't know you pressed the "A" key on your keyboard? What if that "A" didn't show up on the screen? What if you sent an email and the "A" didn't arrive?
7. Internet Protocol (yes, both versions 4 and 6) - The Internet would not be possible without a standard Internet Protocol. 

So I think we can all agree that these standards are good for us - And thankfully for healthcare, the ANSI (American National Standards Institute) created a new HITSP chapter in 2005 after the ONC recommended someone start working on healthcare IT standards. (A shout out and thanks to John Halamka, MD for taking on this labor of love!) :)

Anyway, I think the take-home message about healthcare IT standards is that we're still really early in the process. (As of this writing, the HITSP has only been around for about 6 years!)

So because a lot of my work as an informaticist deals with the struggles to achieve standards, I think a lot about the final objective of informatics : Getting the right information to the right person in the right place at the right time in the right way. (It's easy to get 2 or 3 of those right, but getting all 5 right is much more difficult.)

Anyway, so it's nor surprising that I eagerly await the day when the Regional Extension Centers (RECs) and Implementation and Optimization Organizations (IOOs) finally make the HIEs that smoothly link our electronic medical records - ... But what then?

A WORD ABOUT STANDARDS FOR CLINICAL DOCUMENTATION

In my quest to get the right information to the right person in the right place at the right time in the right way, it dawns upon me that the best technical solutions may still fall short of expectations because of this : There aren't really any good standards for the content of electronic documentation.

In fact, I started to ponder - What standards are there, at all, for clinical documentation?

Most practicing physicians can pretty quickly think of one real standard - The SOAP note. It stands for "Subjective, Objective, Assessment, and Plan", and is a rough outline for how you write a note in a logical way :

S - Subjective - What you heard from the patient (history, opinions, and answers)
O - Objective - What you saw about the patient (measurable things or physical findings)
A - Assessment - What you believe is currently going on with your patient
P - Plan - What you and your patient are going to do about it

The SOAP note is also a cognitive framework for how we think and communicate about patients - When you sign out to another physician, the SOAP note influences our thinking and what we say or write about our patients. By forcing a physician to confront the evidence (S, O) before rendering an opinion (A) and plan (P), it has had a remarkable impact in improving the quality of care and communication about that care.

Interestingly, the history of the SOAP note goes back to this seminal paper written by Dr. Lawrence Weed, published in the March 14th, 1968 edition of the New England Journal of Medicine. (Click on the link above to read the actual article.) 

** IF YOU WORK IN HEALTH INFORMATICS, YOU SHOULD READ THE ORIGINAL ARTICLE IN ITS ENTIRETY. **

One of the fascinating parts about this article is in its opening paragraphs - The purpose of this paper, in 1968, was "...to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel and a more positive attitude about the computer in medicine." Snark Alert : Amazing how far we've come in the last 43 years!

But getting back to serious discussion, the paper highlights many of the struggles we have had with implementing EMRs in the last 40 years - And still continue to struggle with today. When you read the article and see how notes were structured BEFORE the SOAP structure, you can see why some people argue he should win a Nobel Prize for Medicine. 

It's also good to know Dr. Weed is still developing his argument, as published in this 1997 British Medical Journal article. (THANK YOU DR. WEED!)

But then I thought : We have the SOAP note - But do we have anything else to help guide us?

Since most medical schools teach little about clinical documentation (you're usually too busy learning about diseases), many doctors finally learn about note writing from pocket books like the Washington Manual Intern Survival Guide. (Similarly-themed but shorter "Intern Survival Guides" can be found here and here, just to get an idea of what I'm talking about.)

So if most of our education for physicians about writing notes falls down to these pocket guides, and the notes are often specialty-dependent but built on the SOAP framework - It's no wonder we all struggle with electronic documentation.

A WORD ABOUT THE STRUGGLES OF ELECTRONIC DOCUMENTATION

Anyone who has worked on electronic documentation will tell you : It's hard to build, and hard to maintain.

The first challenge is getting a note built - What exactly will you use the note for? What will you name it? What do you want to include in the note?

Looking for answers to these questions often depends on :

1. The planned clinical scenario
2. The physician's experience
3. The physician's pocket guide they learned from in Internship
4. Regulatory and compliance issues (the stuff that insurers and other regulators want to read about)

The funny thing is, every hospital is working on this same problem separately - Often coming out with similar but slightly different results. It's a great example of "everyone rebuilding the wheel".

Why can't all Medicine History and Physicals look the same? In my experience, most of them approximate the same SOAP format, but I've even heard the argument, "I'd like to see the Plan at the TOP of the note when I read it." This speaks to a challenge of documentation in general - 

1. Documentation is closely tied with our cognitive processes.
2. Our cognitive processes, while similar, are not entirely standardized.
3. Regulations, insurer demands, and clinical practices change frequently, making it important to maintain notes after they're built.

So in the end, clinical documentation is more expensive to build and maintain than most people imagine - And every hospital is having the same struggles together.

And because the notes may vary in their end result - An electronic note sent from a doc in one hospital one day may not have the best reception by the physician at another hospital.

In other words : I'm thrilled we're working to link our EMRs - But will the notes we send be equally effective at another hospital?

THE INTERSTATE-91 INFORMATICS PROJECT

So we have a new, small, informal group of volunteer healthcare informaticists here along the Interstate 91 Corridor that stretches between New Hampshire/Vermont, all the way down through Massachusetts to New Haven, CT. We meet informally every 3-4 months for dinner to discuss healthcare informatics, and I'm glad to report we recently obtained a donated website, which we hope to develop. 

I'm hoping at our next dinner to propose a few crazy ideas to our group : 

1. What if all of our documentation looked the same? (for the same clinical scenario...)
2. Could all of our clinical documentation look the same? (for the same clinical scenario...)
3. Could we develop a standard for content of electronic documentation?
4. Could we help further develop the SOAP note, to provide a logical and cognitive standard that helps improve care and reduce costs for all of us?
5. Could this framework be used as a teaching tool about clinical documentation in medical schools and residency programs?

Will let you know how things turn out after our next dinner. Look out for the I91 Standards. :) (Ooh, another cliffhanger, I know!)

As always, I love to answer questions. Feel free to respond with thoughts, questions, ideas, or other discussions. Remember : Education is a priority! :)