Creating accurate and comprehensive clinical documentation is essential for hospitalists to ensure quality patient care and effective communication among healthcare providers. The Hospitalist History and Physical (H&P) is a crucial document in this process, detailing the patient's current and past medical history, examination findings, and treatment plans. Here, we will explore how to correctly write and format a Hospitalist H&P using the provided template as a guide.

Chief Complaint

Start with the patient's main issue or symptom, succinctly stating the complaint. For instance, "Severe abdominal pain and vomiting" highlights the primary reason for the patient's visit.

History of Presenting Illness

This section details the patient's current symptoms and their progression. Include relevant past medical history and recent interventions. For example, "A 45-year-old male with a history of hypertension and type 2 diabetes presented with sudden onset of severe abdominal pain radiating to the back, accompanied by nausea and vomiting. Symptoms began 12 hours prior to admission. The patient reports no alleviating factors and states the pain is constant and severe."

Past Medical History, Medications, and Allergies

Document the patient's medical history, current medications, and any known allergies to provide context for their current condition. For example, "Hypertension, Type 2 Diabetes," "Lisinopril 10 mg daily, Metformin 500 mg twice daily," and "No known drug allergies."

Social and Family History

Include lifestyle habits and family medical history to assess potential risk factors. For instance, "The patient is a non-smoker, consumes alcohol occasionally, is married, and lives with his spouse and two children. Father had a history of coronary artery disease."

Review of Systems

Conduct a thorough review of each body system to identify any additional symptoms. Summarize findings such as, "Gastrointestinal: Reports nausea, vomiting, and abdominal pain."

Physical Exam

Document vital signs and examination findings, focusing on abnormalities. For example, "Vitals: Blood pressure 140/90 mmHg, Heart rate 95 bpm, Temperature 37.5°C. Abdominal examination: Tenderness in the epigastric region, guarding present."

Lab and Imaging Results

Summarize relevant laboratory and imaging findings to support your clinical assessment. For example, "Elevated serum amylase and lipase levels. CT scan of the abdomen showed inflammation of the pancreas consistent with acute pancreatitis."

Assessment and Plan

Provide a diagnosis, differential diagnoses, planned investigations, treatments, and referrals. For instance, "Acute Pancreatitis - Impression: Acute pancreatitis. Differential diagnosis: Gallstone pancreatitis, Alcohol-induced pancreatitis. Investigations planned: Liver function tests, Ultrasound of the abdomen. Treatment planned: NPO (nil per os), IV fluids, Pain management with analgesics. Relevant referrals: Gastroenterology consult."

Two Midnight Documentation and Time Spent

Include expected hospital stay duration and time spent on the case to justify admission status and resource utilization. For example, "The patient's stay will likely span more than 2 midnights in the hospital because of the severity of illness. Total time spent: 1 hour."

While mastering clinical documentation is crucial, the process can be time-consuming and detract from patient care. This is where AI medical scribes like Notis AI Medical Scribe come into play, offering a transformative solution for hospitalists.

Streamlining Documentation with Notis AI Medical Scribe

Notis AI Medical Scribe utilizes advanced voice-to-text technology to convert patient interactions into structured SOAP notes. This integration significantly reduces the time spent on documentation by up to 80%, allowing physicians to focus more on patient care. By automating the transcription process, Notis ensures accuracy and comprehensiveness in medical notes, enhancing the quality of patient documentation.

Moreover, Notis operates seamlessly through familiar platforms like WhatsApp, eliminating the need for additional software. This ease of use, combined with high accuracy and multilingual support, makes Notis an ideal tool for physicians looking to streamline their documentation workflow and improve efficiency.

Incorporating AI medical scribes like Notis into clinical practice not only enhances documentation efficiency but also ensures that healthcare providers can dedicate more time to patient interactions, ultimately improving patient outcomes and satisfaction.