History and Physical Form
Purpose of the Tool: To provide a uniform
system for recording a history and physical for all patients upon
Submitter: Lindsay M. Arnold,
Tool Author: (if not the same as
the submitter):Jeff Greenwald, MD
Tool Implemented: Winter 2005
Institution: Boston Medical Center
Institution: 547-bed academic, inner-city medical
Tool Format (paper-based, computer-based,
on handheld etc….): Paper-based.
Using this Tool:
Tips on Using this Tool:
- Provides a format conducive to
admission by any service.
- Medication history section encourages
review of all medications taken by a patient, such as herbals and
- Encourages medication
reconciliation on admission by challenging the clinician to think about
each medication a patient is taking should be continued upon
- Promote multidisciplinary aspect by encouraging nurses,
pharmacists, physicians and other clinicians to update the history as
new information is learned.
Resources Used to Develop Tool:
- Currently not about to be linked to electronic hospital
- Mulidisicplinary committee of various services and clinicians.