Clinical meaning
The comprehensive history and physical examination (H&P) is the cornerstone of advanced practice nursing. Unlike the focused assessment performed by RNs, the advanced H&P involves autonomous clinical decision-making, differential diagnosis formulation, and the integration of subjective and objective data to determine a medical diagnosis and treatment plan. The H&P follows the traditional medical model with nursing integration: 1. Chief Complaint (CC): In the patient's own words. Example: 'I've had chest pain for 3 hours.' 2. History of Present Illness (HPI): The most critical component. Uses OLDCARTS expanded with: • Onset: Sudden vs gradual, what was patient doing? • Location: Precise anatomical location, radiation pattern • Duration: Constant vs intermittent, total duration, episode length • Character: Patient's description of quality (sharp, dull, pressure, burning, tearing) • Associated symptoms: What else occurred? (nausea, diaphoresis, SOB, fever) • Aggravating/Relieving factors: Position, activity, food, medications tried • Timing: Time of day, relationship to meals/activity/sleep • Severity: 0-10 scale, impact on function, comparison to prior episodes • Context: What does the patient think is wrong? What are they most concerned about? 3. Past Medical History:...