Overview
A History and Physical (H&P) is the comprehensive clinical assessment performed at the time of hospital admission or initial evaluation for a new patient. It documents the patient's complete medical history, chief complaint, history of present illness, detailed physical examination, medication list, allergies, review of systems, family and social history, and initial treatment plan. The H&P is the foundational document that anchors inpatient care and supports both clinical and financial aspects of the admission.
CMS Conditions of Participation (42 CFR §482.22) require that an H&P be completed and documented by a physician, dentist, oral surgeon, or certain other qualified practitioners within 24 hours of admission. The H&P must be placed in the medical record before any surgery or procedure (except in emergencies), and the document must be signed. An outpatient H&P performed within 30 days prior to admission may be used, with an admission interval note documenting that the H&P remains current.
Content requirements are comprehensive. The history component captures chief complaint, present illness history, past medical and surgical history, medications, allergies, family history, social history, and review of systems. The physical exam component documents vital signs and organ-system exam findings appropriate to the admission. The assessment synthesizes clinical impression with differential diagnoses. The plan outlines initial diagnostic and therapeutic approach.
For RCM, the H&P is critical to several claim-related workflows. Inpatient admission medical-necessity review uses the H&P to justify inpatient status — the clinical severity documented must support admission criteria under InterQual or MCG. DRG-related CDI focuses on the H&P as the primary source for principal diagnosis, secondary diagnoses, and present-on-admission (POA) indicators. Medical-necessity audits (RAC, MAC, ZPIC) begin with the H&P as the clinical narrative supporting the admission.
Documentation quality directly affects reimbursement. An H&P with vague assessment ('admit for observation of chest pain') supports weaker DRG assignment than an H&P with specific assessment ('unstable angina with positive troponin, admit for cardiac telemetry and cardiology consult'). Similarly, complete secondary-diagnosis capture in the H&P drives DRG severity (with or without CC/MCC) and quality-measure attribution. Organizations with strong CDI programs often focus H&P improvement as high-leverage documentation work.
From a clinical-documentation standpoint, History and Physical closes the gap between bedside reality and billing-ready text. Providers who treat History and Physical as a downstream billing chore rather than a first-pass clinical summary almost always produce documentation that fails soap note audits and drives avoidable clinical documentation improvement queries. The editorial convention on this site is to frame History and Physical as a structured clinical artifact whose quality is measured by how seldom it requires a later amendment.
Industry benchmark
CMS Conditions of Participation §482.22. Joint Commission standards on H&P completeness and timing. Document completeness audits typically focus on timing (within 24 hours), signature, and content adequacy.
Worked example
A 72-year-old male admitted through the ED with chest pain. H&P documents: CC 'retrosternal chest pain × 3 hours'; HPI detailed pressure radiating to left arm, associated diaphoresis, relieved with NTG; PMH HTN, HLD, T2DM with neuropathy (HCC-qualifying), CAD s/p 3-vessel CABG 2018; detailed cardiac, pulmonary, and extremity exam; Assessment: acute NSTEMI (I21.4), prior CAD, T2DM with complications (E11.42 — HCC), HTN, HLD; Plan: cardiology consult, telemetry, ASA, heparin, beta blocker, statin, NPO for possible cath. The H&P supports inpatient admission criteria, drives CDI-optimized DRG assignment, and anchors subsequent documentation and coding.
Frequently asked questions — History and Physical
When must an H&P be completed?
Within 24 hours of inpatient admission per CMS Conditions of Participation. Must be in the medical record before surgery or invasive procedures (with emergency exceptions). Outpatient H&P performed within 30 days before admission may be used with an admission interval note.
Who can perform an H&P?
Physicians, dentists for dental admissions, oral maxillofacial surgeons for OMFS admissions, and certain other qualified practitioners as defined by the hospital's medical staff bylaws. Physician assistants and nurse practitioners can perform and document H&Ps under supervision rules that vary by state and hospital bylaws.
How does H&P quality affect reimbursement?
Directly. The H&P is the primary source for principal diagnosis, secondary diagnoses, and severity coding that drives DRG assignment. Specific, well-reasoned H&P documentation supports higher-acuity DRGs; vague documentation produces lower DRG assignment. CDI programs focus H&P improvement as high-leverage documentation work.
What about outpatient encounters — is there an H&P?
The comprehensive H&P format is typically used for new-patient outpatient visits and some specialty consultations. Established-patient follow-up visits use abbreviated encounter notes (often SOAP-formatted) that focus on the interval change since last visit. H&P-scale documentation at every visit would be excessive for routine care.
Disclaimer
This glossary entry is operational reference for revenue-cycle and medical-billing professionals. It is not legal, clinical, or contractual advice. Industry benchmarks cite named public sources where available; always verify against the current guidance from the authority body before relying on a number in a contract, policy, or compliance filing.