Evaluation of Student H&P UNC Medicine Inpatient Clerkship
Student Name: Date Submitted:
When Dr. Klipstein evaluates an H&P, he will consider the following issues:
History of Includes a chief complaint
Present Illness Appropriate dimensions of cardinal symptom are listed (including location, severity,
quality, setting, chronology, aggravating/alleviating, associated manifestations)
Chronological story begins at baseline state of health
Incorporates elements of PMH, FH, SH that are relevant to story (e.g. includes risk
factors for CAD for patient with chest pain)
ROS questions pertinent to chief complaint are included in HPI (not in ROS section)
HPI reflects knowledge of differential diagnosis
HPI narrative flows smoothly, in a logical fashion
Past Medical Includes sufficient detail (onset, complications, and therapy) for key diagnoses (e.g.,
History Type 2 DM, on pills since 1995, mild neuropathy, no known retinopathy/nephropathy)
Medications Includes dose, route and frequency for each medication
Includes over the counter and herbal remedies
Allergies Includes nature of adverse reaction
Review of Most systems are evaluated (e.g. Constitutional, HEENT, Respiratory, Cardiovasc,
Systems GI, GU, Neuro, Psych, Endocrine, Musculoskeletal, Hematologic/ Lymph, Skin)
Does not include PMH (ex. Cataracts or heart murmur belong in PMH, not ROS)
Does not repeat information already in HPI
Adequate depth (e.g. GI: no abdominal pain, bloating, nausea, vomiting,
melena, hematochezia, change in color, caliber, consistency or frequency of stool)
Social History Occupation, marital status
Tobacco, EtOH, and substance abuse
Functional status, living situation
Family History State of health of parents, siblings, children
Extended family occurrence of CAD, DM, HTN and cancer
Age at diagnosis of important diseases, especially if premature onset (e.g. CAD in
brother age 37, colon cancer in father age 42)
Physical Includes areas relevant to the chief complaint (e.g. for patient with cirrhosis includes
Examination presence/absence of stigmata of liver disease, for patient with CHF in differential
diagnosis includes presence/absence of JVD, crackles, murmur, gallops, liver size,
edema, etc)
Does not include assessments/interpretations in PE section (e.g. describes “8x10cm
oval area of warm, erythematous skin on medial aspect of left thigh” instead of
“cellulitis on medial aspect of left thigh”)
Physical Includes general description
Examination, Includes vital signs (including O2 sats, orthostatics, and pain level when appropriate)
continued Includes skin examination
Includes lymph node survey (not limited to neck nodes only)
Includes thyroid examination
Respiratory includes more than “clear to auscultation”
Cardiovascular includes assessment of neck veins, and distal pulses
Abdominal examination includes measured liver span
Includes rectal exam (or reasonable statement as to why not performed)
Neurologic examination includes mental status, cranial nerves, strength, sensation,
cerebellar function and reflexes
Laboratory and Includes lab data appropriate for HPI
Other Studies Lab data adequately reported (e.g. includes intervals on EKG for patient with syncope)
Problem List Includes all active medical problems
Includes significant abnormalities in physical examination and laboratory studies
Includes health maintenance/screening issues when appropriate
Discussion/ Includes sentence summarizing key history, PE and laboratory data
Assessment Discussion is specific to the patient, not a summary of textbook or review article
And Plans Adequate differential diagnosis reviewed for major problems
Evaluation/diagnostic strategy proposed (or reviewed if already performed)
Management strategy discussed
Reflects an understanding of the pathophysiology of the patient’s illness
Style Legible
Not laden with spelling or grammatical errors
Uses medical abbreviations appropriately, does not coin own abbreviations
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