Comprehensive Women’s Health History and Physical Template
Encounter date:
Patient Initials: Gender: Age: Race/Ethnicity:
Reason for Seeking Health Care
History of Present Illness (HPI)
Allergies (Drug/Food/Latex/Environmental/Herbal)
Current Perception of Health
Current Medications (including over the counter)
Menstrual History
Age at Menarche
Last menstrual period
Menstrual Pattern
Cycle Length
Duration of Flow
Amount of Flow
Bleeding Pattern
Break through Bleeding
Gynecologic History
History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)
Previous GYN surgery (may include that in surgical history)
History of infertility
History of diethylstilbestrol (DES) use by patient’s mother
Last pap smear, history of abnormal pap
Pre-menopause/menopause
Vasomotor symptoms
Hormone Replacement Therapy
Sexual and Contraceptive History
Current method of contraception
Sexually active
Number of sexual partners
New partners in the 3-6 months
Condom use
History of sexual abuse
History of sexually transmitted infections (STIs)
Obstetric History (including complications)
Past Medical History (PMH)
Major/Chronic Illnesses
Trauma/Injury
Hospitalizations
Past Surgical History
Family Medical History
Social History
Living condition
Marital status
Education
Employment
Occupation
Social supports
Habits (smoking, alcohol use and illicit drugs use)
Health Maintenance
Age-appropriate health promotion/maintenance and screening history
Immunization history
Review of Systems (ROS)
General
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic
Physical Examination
Vital Signs
Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)
Height Weight Body Mass Index (BMI) Pain
General Appearance
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic
Significant Data/Contributing Dx/Labs/Misc
Assessment
Differential Diagnoses (3 minimum)
Primary Diagnoses
Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)
Diagnoses
Laboratory/Diagnostic Studies
Therapeutic (Non-pharmacological interventions)
Pharmacological Therapy
Patient Education/Anticipatory Guidance
Referrals
Follow up
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Signature (with appropriate credentials): __________________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
5
Joseph, M. V. (2021). Women’s Health Comprehensive H & P. Copyright ©
D
istinguised
E
xcellent
F
air
P
oor
Includes a direct quote from
patient about
presenting problem
Includes a direct quote from
patient and other
unrelated inform
ation
Includes inform
ation but inform
ation is N
O
T
a
direct quote
Inform
ation is com
pletely m
issing
4 P
oints
3 P
oints
2 P
oints
0 P
oints
B
egins w
ith patient initials, age, race,
ethnicity and gender (5 dem
ographics)
B
egins w
ith 4 of the 5 patient dem
ographics
(patient initials, age, race, ethnicity and gender)
B
egins w
ith 3 or less patient dem
ographics
(patient initials, age, race, ethnicity and gender)
Inform
ation is com
pletely m
issing
2 P
oints
1.5 P
oints
1 P
oints
0 P
oints
Includes the presenting problem
and the 8
dim
ensions of the problem
(O
LD
C
A
R
T
S –
O
nset, Location, D
uration, C
haracter,
A
ggravating factors, R
elieving factors,
T
im
ing and Severity)
Includes the presenting problem
and 7 of the 8
dim
ensions of the problem
(O
LD
C
A
R
T
S –
O
nset, Location, D
uration, C
haracter,
A
ggravating factors, R
elieving factors, T
im
ing
and Severity)
Includes the presenting problem
and 6 of the 8
dim
ensions of the problem
(O
LD
C
A
R
T
S –
O
nset, Location, D
uration, C
haracter,
A
ggravating factors, R
elieving factors, T
im
ing
and Severity)
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
Includes N
K
A
(including = D
rug,
E
nvironem
ental, Food, H
erbal, and/or Latex
or if allergies are present (reports for each
severity of allergy A
N
D
description of
allergy)
If allergies are present, students lists type D
rug,
environem
tal factor, herbal, food, latex nam
e and
includes severity of allergy O
R
description of
allergy
If allergies are present, students lists only the
type of allergy nam
e
Inform
ation is com
pletely m
issing
2 P
oints
1.5 P
oints
1 P
oints
0 P
oints
Includes a m
inim
um
of 3 assessm
ents for
each body system
and assesses at least 9
body system
s directed to chief com
plaint
A
N
D
uses the w
ords “adm
its” and “denies”
Includes 3 or few
er assessm
ents for each body
system
and assesses 5-8 body system
s directed to
chief com
plaint A
N
D
uses the w
ords “adm
its”
and “denies”
Includes 3 or few
er assessm
ents for each body
system
and assesses less than 5 body system
s
directed to chief com
plaint O
R
student does not
use the w
ords “adm
its” and “denies”
Inform
ation is com
pletely m
issing
12 P
oints
6 P
oints
3 P
oints
0 P
oints
Includes all 8 vital signs, (B
P (w
ith patient
position), H
R
, R
R
, tem
perature (w
ith
Fahrenheit or C
elsius and route of
tem
perature collection), w
eight, height, B
M
I
(or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (B
P (w
ith patient position),
H
R
, R
R
, tem
perature (w
ith Fahrenheit or C
elsius
and route of tem
perature collection), w
eight,
height, B
M
I (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (B
P (w
ith patient
position), H
R
, R
R
, tem
perature (w
ith Fahrenheit
or C
elsius and route of tem
perature collection),
w
eight, height, B
M
I (or percentiles for pediatric
population) and pain.)
Inform
ation is com
pletely m
issing
2 P
oints
1.5 P
oints
1 P
oints
0 P
oints
Includes a list of the labs review
ed at the
visit, values of lab results and highlights
abnorm
al values O
R
acknow
ledges no
labs/diagnostic tests w
ere review
ed.
Includes a list of the labs review
ed at the visit,
values of lab results but does not highlight
abnorm
al values.
Includes a list of the labs review
ed at the visit but
does not include the values of lab results or
highlight abnorm
al values.
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes a list of all of the patient reported
m
edications and the m
edical diagnosis for
the m
edication (including nam
e, dose, route,
frequency)
Includes a list of all of the patient reported
m
edications and the m
edical diagnosis for the
m
edication (including 3 of the 4: nam
e, dose,
m
edications route, frequency)
Includes a list of all of the patient reported
m
edications (including 2 of the 4: nam
e, dose,
route, frequency)
Inform
ation is com
pletely m
issing
Subjective
O
bjective
M
edications
Labs
R
eview
of System
s (R
O
S)
H
istory of the P
resent Illness (H
P
I)
D
em
ographics
C
hief C
om
plaint (R
eason for seeking
health care)
A
llergies
V
ital Signs
4 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes an assessm
ent of at least 5
screening tests
Includes an assessm
ent of at least 4 screening
tests
Includes an assessm
ent of at least 3 screening
tests
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes (M
ajor/C
hronic, T
raum
a,
H
ospitaliztions), for each m
edical diagnosis,
year of diagnosis and w
hether the diagnosis
is active or current
Includes (M
ajor/C
hronic, T
raum
a,
H
ospitaliztions), for each m
edical diagnosis,
either year of diagnosis O
R
w
hether the diagnosis
is active or current
Includes each m
edical diagnosis but does not
include year of diagnosis or w
hether the
diagnosis is active or current
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes, for each surgical procedure, the
year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of
procedure O
R
indication of the procedure
Includes, for each surgical procedure but not the
year of procedure or indication of the procedure
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes an assessm
ent of at least 4 fam
ily
m
em
bers regarding, at a m
inim
um
, genetic
disorders, diabetes, heart disease and
cancer.
Includes an assessm
ent of at least 3 fam
ily
m
em
bers regarding, at a m
inim
um
, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessm
ent of at least 2 fam
ily
m
em
bers regarding, at a m
inim
um
, genetic
disorders, diabetes, heart disease and cancer.
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes all of the follow
ing: tobacco use,
drug use, alcohol use, m
arital status,
em
ploym
ent status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
Includes 10 of the 11 follow
ing: tobacco use,
drug use, alcohol use, m
arital status, em
ploym
ent
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the follow
ing: tobacco use,
drug use, alcohol use, m
arital status, em
ploym
ent
status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,
and living situation.
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes a m
inim
um
of 4 assessm
ents for
each body system
and assesses at least 5
body system
s directed to chief com
plaint
Includes a m
inim
um
of 3 assessm
ents for each
body system
and assesses at least 4 body system
s
directed to chief com
plaint
Includes a m
inim
um
of 2 assessm
ents for each
body system
and assesses at least 4 body system
s
directed to chief com
plaint
Inform
ation is com
pletely m
issing
12 P
oints
6 P
oints
3 P
oints
0 P
oints
Includes a clear outline of the accurate
principal diagnosis A
N
D
lists the rem
aining
diagnoses addressed at the visit (in
descending priority)
Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal
diagnosis
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
Includes at least 3 differential diagnoses for
the principal diagnosis
Includes 2 differential diagnoses for the principal
diagnosis
Includes 1 differential diagnosis for the principal
diagnosis
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
D
iagnosis
A
ssessm
ent
P
lan
F
am
ily H
istory
Screenings
P
ast M
edical H
istory
D
ifferential D
iagnosis
Social H
istory
P
ast Surgical H
istory
P
hysical E
xam
ination
Includes a detailed pharm
acologic treatm
ent
plan for each of the diagnoses listed under
“assessm
ent”. T
he plan includes A
LL of
the follow
ing: drug nam
e, dose, route,
frequency, duration and cost as w
ell as
education related to pharm
acologic agent. If
the diagnosis is a chronic problem
, student
includes instructions on currently prescribed
m
edications as above.
Includes a detailed pharm
acologic treatm
ent plan
for each of the diagnoses listed under
“assessm
ent”. T
he plan includes 4 of the
follow
ing 7: the drug nam
e, dose, route,
frequency, duration and cost as w
ell as education
related to pharm
acologic agent. If the diagnosis is
a chronic problem
, student includes instructions
on currently prescribed m
edications as above.
Includes a detailed pharm
acologic treatm
ent plan
for each of the diagnoses listed under
“assessm
ent”. T
he plan includes less than 4 of
the follow
ing: the drug nam
e, dose, route,
frequency, duration and cost as w
ell as education
related to pharm
acologic agent. If the diagnosis
is a chronic problem
, student includes
instructions on currently prescribed m
edications
as above.
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
Includes appropriate diagnostic/lab testing
100%
of the tim
e O
R
acknow
ledges “no
diagnostic testing clinically required at this
tim
e”
Includes appropriate diagnostic/lab testing 50%
of the tim
e O
R
acknow
ledges “no diagnostic
testing clinically required at this tim
e”
Includes appropriate diagnostic testing less than
50%
of the tim
e.
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
Includes at least 3 strategies to prom
ote and
develop skills for m
anaging their illness and
at least 3 self-m
anagem
ent m
ethods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to prom
ote and
develop skills for m
anaging their illness and at
least 2 self-m
anagem
ent m
ethods on how
to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to prom
ote and
develop skills for m
anaging their illness and at
least 1 self-m
anagem
ent m
ethods on how
to
incorporate healthy behaviors into their lives.
Inform
ation is com
pletely m
issing
5 P
oints
3 P
oints
2 P
oints
0 P
oints
Includes at least 3 prim
ary prevention
strategies (related to age/condition (i.e.
im
m
unizations, pediatric and pre-natal
m
ilestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 prim
ary prevention strategies
(related to age/condition (i.e. im
m
unizations,
pediatric and pre-natal m
ilestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 prim
ary prevention strategies
(related to age/condition (i.e. im
m
unizations,
pediatric and pre-natal m
ilestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Inform
ation is com
pletely m
issing
4 P
oints
2 P
oints
1 P
oints
0 P
oints
Includes recom
m
endation for follow
up,
including tim
e fram
e (i.e. x # of
days/w
eeks/m
onths)
Includes recom
m
endation for follow
up, but does
not include tim
e fram
e (i.e. x # of
days/w
eeks/m
onths)
D
oes not include follow
up plan
4 P
oints
2 P
oints
0 P
oints
0 P
oints
H
igh level of A
PA
precision
M
oderate level of A
PA
precision
Incorrect A
PA
style
Inform
ation is com
pletely m
issing
3 P
oints
2 P
oints
1 P
oints
0 P
oints
Free of gram
m
ar and spelling errors
W
riting m
echanics need m
ore precision and
attention to detail
W
riting m
echanics need serious attention
3 P
oints
2 P
oints
0 P
oints
0 P
oints
P
harm
acologic treatm
ent plan
F
ollow
up plan
W
riting
G
ram
m
ar
R
eferences
D
iagnostic/Lab Testing
A
nticipatory G
uidance
E
ducation
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