History and physical (H&P) template

An H&P is the comprehensive baseline: the note written when a patient is admitted or seen in full for the first time. This page gives a copyable H&P layout, a completed invented admission example, the gaps reviewers most often find, and a straight answer on which ClearPass structure fits an H&P best.

What an H&P has to cover

Unlike a focused visit note, the H&P is meant to be complete. Later notes refer back to it, so missing background here tends to stay missing. The sections below are the ones most services expect, in the usual order.

• Chief complaint and history of present illness: why the patient is here now, told as a timeline with pertinent positives and negatives.
• Past medical and surgical history: diagnoses with dates or duration where known, and operations.
• Medicines and allergies: name, dose, frequency, and the reaction for each allergy.
• Family and social history: conditions in first-degree relatives; smoking, alcohol, occupation, living situation, function.
• Review of systems: a short system-by-system screen for symptoms not already covered.
• Physical examination: vital signs, general appearance, then each system examined.
• Data: blood tests, imaging and ECG available at the time.
• Assessment and plan: a summary line, the problem list, and the plan for each problem.

Blank H&P template

HISTORY AND PHYSICAL
Date and time: [date, time]
Source of history: [patient / relative / transfer notes]

Chief complaint:
History of present illness:

Past medical history:
Past surgical history:
Medicines:
Allergies (with reaction):
Family history:
Social history: smoking / alcohol / occupation / home / baseline function

Review of systems:
  General:
  Cardiovascular:
  Respiratory:
  Gastrointestinal:
  Genitourinary:
  Neurological:
  Musculoskeletal and skin:

Physical examination:
  Vitals: BP / HR / RR / Temp / SpO2
  General:
  Head and neck:
  Cardiovascular:
  Respiratory:
  Abdomen:
  Extremities and skin:
  Neurological:

Investigations:

Summary:
Assessment and plan by problem:
  1.
  2.
Code status / escalation discussion: [if applicable]

Filled example: admission for leg cellulitis

Chief complaint: red, painful left lower leg for 3 days.
HPI: 64-year-old noticed a small crack between the left 4th and 5th toes a week ago. Redness began above the ankle 3 days ago and has spread to mid-shin despite 2 days of oral flucloxacillin from primary care. Fever and shivers last night. No calf swelling before the redness, no recent travel.
PMH: type 2 diabetes (8 years), hypertension, obesity. PSH: appendicectomy.
Medicines: metformin 1 g twice daily, lisinopril 10 mg daily. Allergies: none known.
Family history: father had type 2 diabetes. Social: lives with partner, retired driver, non-smoker, alcohol rarely, independent.
ROS: no chest pain, no breathlessness, no urinary symptoms, no diarrhoea.
Exam: BP 132/78, HR 102, RR 18, Temp 38.4, SpO2 97% air. Alert, flushed. Heart sounds normal. Chest clear. Abdomen soft, non-tender. Left leg: warm, tender erythema from ankle to mid-shin with marked edge, no crepitus, no blistering; interdigital fissure 4th/5th toes. Pedal pulses present. Right leg normal.
Investigations: WBC 14.2, CRP 118, glucose 13.6, creatinine at baseline.
Summary: 64-year-old with diabetes and left leg cellulitis spreading despite oral antibiotics, febrile.
Plan:
1. Cellulitis: IV antibiotics per local protocol (team decision), mark erythema edge, elevate leg, blood cultures, review at 48 hours.
2. Diabetes: metformin held while acutely unwell, capillary glucose four times daily.
3. Tinea pedis as portal of entry: topical antifungal.

Gaps that weaken an H&P

• Allergies written as none without asking, or listed without the reaction.
• Baseline function missing, which matters later for discharge planning.
• A review of systems stated as all negative when only two systems were asked about.
• An examination template left with default normal text for systems that were not examined.
• No summary line, so every reader has to build the picture themselves.

Which ClearPass structure fits an H&P

ClearPass has no structure named H&P, so here is the honest mapping. New patient is the closest for a first full assessment: it writes today's problem and the full background history, including past medical history, medicines, allergies, family and social history. Full headings gives nine sections from presenting complaint to plan and suits an admission-style note. If your service needs a system-by-system review and examination laid out exactly as above, save those headings once under My own structure and reuse them.

Two limits matter. First, ClearPass writes only what was said or typed. Much of an examination happens in silence, so say the findings aloud or type them in, including the normal ones you want documented; otherwise those lines stay empty. Second, the note is an AI draft that you review before it goes into the chart. Results can be added by photographing the lab report, and ClearPass reads the clinical details into the note. For shorter first visits in clinic, see the new patient note template.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Related

• New patient visit note template
• Progress note template
• An AI documentation aid for hospitalists
• An AI medical scribe for internal medicine
• Custom note templates: build headings that fit your clinic