Medical records
History and physical (H&P)
The history and physical is the comprehensive intake document of a hospital admission — the patient's account of the present illness and past history plus a full examination — and usually the single densest page-range in a medical file.
A standard H&P contains: chief complaint; history of present illness (HPI — the narrative of what happened and since when); past medical and surgical history; medications and allergies; family and social history; review of systems (ROS — the head-to-toe symptom checklist); the physical examination; and the assessment and plan. Hospitals require one at admission, and surgeons dictate focused versions pre-operatively.
Why it matters for legal readers
The H&P is testimony by another name. The HPI is the patient’s account of the incident, told for treatment rather than litigation — often within hours of the event — which gives it both credibility and hearsay advantages, and makes it the first place to check the claimed mechanism of injury (“fell from ladder, ~8 feet” vs. what the complaint later says). Past-history sections are the preexisting-condition census: prior injuries, surgeries, and complaints, listed before anyone was thinking about a lawsuit.
The social history deserves its own read — work status, substance use, living situation — as both damages context and impeachment risk. And discrepancies between H&Ps (this admission’s history versus last year’s) are the quiet contradictions that decide credibility.
In the fact record
H&P content fans out across every issue in an injury case, which is why extracting it fact-by- fact — each statement dated, attributed, and cited — pays off more here than anywhere else in the chart.