Below are some web sites with some more information on History & Physicals. Many of the sites also provide example write-ups. There is no one, absolutely correct template for creating the perfect write-up. However, the more you understand the fundamental principles of performing and writing-up an H&P, and the more examples of high quality write-ups you encounter, the better prepared you will be to create your own well-written History & Physicals.
Case-Based Curriculum of Clinical Medicine – The Physical Exam:
Cases, questions, images, etc. are provided for medical education by Assistant Professor of University of Chicago. Family Medicine; Geriatrics; Cardiology-Med; Infectious Diseases-Med; Immunology-Med; Pulmonology-Medicine; Hematology & Oncology-Med; Endocrinology-Med; Neurology.
An example of an incredibly detailed write-up.
University of California San Diego - UCSD Practical Guide to Clinical Medicine
This site describes well the important elements of a good H&P and provides several examples. The site also includes links to information on taking a history and performing different elements of the physical exam. Included are digital images, instructions on providing a comprehensive physical examination and other clinical education information.
Department of Medicine Medical Clerkship
Another excellent site that also describes the important elements of a good H&P. Provides annotated examples of writes-up ranging in quality from outstanding to unacceptable.
University of Florida – Physical Exam Study Guides
Physical exam study guides covering; Vital Signs, Back and Extremity Exam, Chest and Lung Exam Cardiovascular Exam, Head and Neck Exam, Eye Exam, Abdominal Exam, Breast Exam, Pelvic Exam, Neurologic Exam, and Mental Status Exam.
Sample written history & physical exam. A write-up with annotated comments describing what makes it a good H&P.
University of Rochester Medical Center - Department of Medicine
This site provides an example of a good patient H & P and write-up as well as an example of a progress note for the same patient for the following day.
University of Virginia - Practice of Medicine
Physical Exam Modules; this site provides links to instructional modules and videos demonstrating physical exam techniques.
University of Washington - Guidelines for Write Up’s by Steve MeGee, MD
This site discusses the basic elements of the H&P and lists some common mistakes.