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History and Physical Form

Purpose of the Tool: To provide a uniform system for recording a history and physical for all patients upon admission.

Submitter: Lindsay M. Arnold, Pharm.D., BCPS

Tool Author: (if not the same as the submitter):Jeff Greenwald, MD

E-mail contact information: 

Date Tool Implemented: Winter 2005

Name of Institution: Boston Medical Center

Description of Institution: 547-bed academic, inner-city medical center

Tool Format (paper-based, computer-based, on handheld etc….): Paper-based.

Key Advantages Using this Tool:

  1. Provides a format conducive to admission by any service.
  2. Medication history section encourages review of all medications taken by a patient, such as herbals and over-the-counter medications.
  3. Encourages medication reconciliation on admission by challenging the clinician to think about each medication a patient is taking should be continued upon admission.
Tips on Using this Tool:
  1. Promote multidisciplinary aspect by encouraging nurses, pharmacists, physicians and other clinicians to update the history as new information is learned.
Important Pitfalls:
  1. Currently not about to be linked to electronic hospital system.
Resources Used to Develop Tool:
  1. Mulidisicplinary committee of various services and clinicians.
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