History and Physical Generator

When to Use This Skill

Use when a clinician needs a comprehensive H&P document for hospital admission or initial specialist consultation.

Clinical Workflow

1. Use fhir_read to retrieve Patient demographics, emergency contacts
2. Use fhir_search to retrieve the admitting Encounter (reasonCode, class=IMP)
3. Use fhir_search to pull all Condition resources: active problems (PMH), encounter diagnoses (admitting diagnosis)
4. Use fhir_search to pull Procedure resources for surgical history
5. Use fhir_search to pull active MedicationRequest and MedicationStatement for home medications
6. Use fhir_search to pull AllergyIntolerance resources
7. Use fhir_search to pull Observation resources: social history (category=social-history), vitals, labs
8. Use fhir_search to pull FamilyMemberHistory resources for family history
9. Assemble H&P in standard format: CC, HPI, PMH, PSH, Medications, Allergies, Social Hx, Family Hx, ROS, Physical Exam, Labs/Studies, Assessment, Plan
10. Optionally use fhir_create to persist as DocumentReference (LOINC 34117-2)

FHIR Resources

• Encounter -- Admission context
• Patient -- Demographics
• Condition -- Active problems (PMH) and admitting diagnoses
• Procedure -- Surgical history
• MedicationRequest / MedicationStatement -- Medications
• AllergyIntolerance -- Allergies
• Observation -- Social history (smoking, alcohol, drugs), vitals, labs
• FamilyMemberHistory -- Family medical history
• DocumentReference -- Output: H&P document

FHIR Query Examples

Pull Surgical History

fhir_search(resourceType="Procedure", queryParams="patient=[patient-id]&_sort=-date&_count=50")

Pull Social History

fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=social-history")

Pull Family History

fhir_search(resourceType="FamilyMemberHistory", queryParams="patient=[patient-id]")

Clinical Guidelines

• CMS H&P documentation requirements for hospital admissions
• Joint Commission medical record standards
• Specialty-specific H&P templates (surgical, medical, psychiatric)

Interpretation Guide

• Structure sections in standard medical H&P order
• PMH: organize by system (cardiovascular, endocrine, neurologic, etc.)
• PSH: list procedures with approximate dates
• Social history: include tobacco (pack-years), alcohol (drinks/week), drug use, occupation, living situation, advance directives
• Family history: organize by first-degree relative with conditions and age of onset/death
• Assessment: primary admitting diagnosis first, then secondary diagnoses numbered by priority
• Plan: per-problem approach with immediate orders, workup plan, and anticipated hospital course

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges