History and Physical Generator

Overview

Generate a comprehensive History and Physical document from FHIR resources. Auto-populate all available structured data including past medical history, past surgical history, medication list, allergy list, family history, social history, and current vital signs/labs. Flag data gaps requiring clinician input. Support regulatory requirements for admission H&P per CMS CoP and TJC standards (must be completed within 24 hours of admission, updated within 30 days if pre-admission H&P exists).

FHIR Resources Used

Resource	Purpose	Key Fields
Patient	Demographics, social determinants	name, birthDate, gender, communication, extension
Encounter	Admission context, reason for admission	class, reasonCode, period, hospitalization
Condition	PMH, current diagnoses	code, clinicalStatus, onsetDateTime, category
Procedure	Past surgical history	code, performedDateTime, status
MedicationRequest	Current and home medications	medicationCodeableConcept, dosageInstruction, status
AllergyIntolerance	Allergies and adverse reactions	code, reaction, clinicalStatus, criticality
FamilyMemberHistory	Family medical history	relationship, condition, deceasedBoolean
Observation	Vitals, labs, social history	code, value[x], category, effectiveDateTime
DocumentReference	Prior H&P documents	type, content, date
CarePlan	Existing care plans	status, intent, category, activity

Instructions

Step 1: Retrieve Admission Encounter

code

Tool: fhir_read
resourceType: "Encounter"
id: "[encounter-id]"

Extract:

•Admitting diagnosis: reasonCode array
•Admission date/time: period.start
•Encounter class: class.code (IMP = inpatient, OBSENC = observation)
•Admitting physician: participant where type.coding.code = "ADM"
•Source of admission: hospitalization.admitSource

If no encounter ID provided:

code

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&class=IMP&status=in-progress&_sort=-date&_count=1"

Step 2: Retrieve Patient Demographics

code

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract: name, DOB (age), gender, preferred language, race/ethnicity from US Core extensions.

Step 3: Pull Past Medical History (PMH)

code

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active,recurrence,remission&_count=100&_sort=-onset-date"

Categorize conditions:

•Active chronic conditions: clinicalStatus=active with onset > 30 days ago
•Active acute conditions: clinicalStatus=active with onset <= 30 days
•Conditions in remission: clinicalStatus=remission (e.g., cancer history)
•Include onset date for each if available from onsetDateTime

Step 4: Pull Past Surgical History (PSH)

code

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&status=completed&_count=100&_sort=-date"

Filter to surgical procedures. Present chronologically with procedure date. Include:

•Procedure name from code.coding[0].display
•Date performed from performedDateTime or performedPeriod.start
•Relevant notes from note

Step 5: Pull Current Medications

code

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active,on-hold&_count=100"

For each medication extract:

•Drug name (prefer RxNorm display)
•Dose and frequency from dosageInstruction
•Route from dosageInstruction.route
•Prescriber from requester
•Intent: distinguish order (active prescription) from plan (intended)

Step 6: Pull Allergies

code

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]&clinical-status=active"

For each allergy:

•Substance from code.coding[0].display
•Reaction type from reaction[0].manifestation[0].coding[0].display
•Severity from reaction[0].severity (mild, moderate, severe)
•Criticality from criticality (low, high, unable-to-assess)

If zero results, explicitly state "NKDA (No Known Drug Allergies)" but flag that allergy review status should be confirmed.

Step 7: Pull Family History

code

Tool: fhir_search
resourceType: "FamilyMemberHistory"
queryParams: "patient=[patient-id]&status=completed"

Organize by relationship:

•Parents: conditions, age of onset, deceased status
•Siblings: conditions
•Grandparents: conditions (if available)
•Flag hereditary risk factors (CAD, diabetes, cancer syndromes)

If no FamilyMemberHistory resources exist, flag as "Family history not documented in structured data."

Step 8: Pull Social History

Search for social history Observations:

code

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=social-history"

Key LOINC codes for social history:

•72166-2: Tobacco smoking status
•11367-0: History of tobacco use
•74013-4: Alcoholic drinks per day
•96842-0: Substance use
•63512-8: Employment status
•76690-7: Sexual orientation
•71802-3: Housing status
•82810-3: Pregnancy status (if applicable)

Step 9: Pull Current Vital Signs

code

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=vital-signs&_sort=-date&_count=10"

Use most recent set. Map by LOINC (same as SOAP note: 8310-5, 8867-4, 9279-1, 85354-9, 29463-7, 8302-2, 59408-5, 39156-5).

Step 10: Pull Recent Labs

code

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&_sort=-date&_count=50"

Group by panel. Flag abnormal values. Include reference ranges from referenceRange.

Step 11: Check for Prior H&P

code

Tool: fhir_search
resourceType: "DocumentReference"
queryParams: "patient=[patient-id]&type=http://loinc.org|34117-2&_sort=-date&_count=1"

LOINC 34117-2 = History and physical note. If found within 30 days, note it as available for update rather than full rewrite (per CMS/TJC).

Step 12: Assemble H&P Document

code

HISTORY AND PHYSICAL
====================
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender]
Admission Date: [date] | Admitting Physician: [physician]
Admitting Diagnosis: [reasonCode]

CHIEF COMPLAINT
---------------
[Encounter reasonCode text]

HISTORY OF PRESENT ILLNESS
---------------------------
[Synthesize from encounter reason, recent conditions, recent observations.
Flag: "HPI requires clinician narrative input" -- structured data provides context only.]

PAST MEDICAL HISTORY
--------------------
[Numbered list from Step 3 with onset dates]
1. [Condition] (onset [date])
2. [Condition] (onset [date])

PAST SURGICAL HISTORY
---------------------
[Numbered list from Step 4 with dates]
1. [Procedure] ([date])
2. [Procedure] ([date])

MEDICATIONS
-----------
[Numbered list from Step 5]
1. [Drug] [dose] [route] [frequency]

ALLERGIES
---------
[List from Step 6 with reactions]
1. [Substance] - [Reaction] (Severity: [severity])

FAMILY HISTORY
--------------
[Organized by relationship from Step 7]
Father: [conditions]
Mother: [conditions]

SOCIAL HISTORY
--------------
Tobacco: [status]
Alcohol: [status]
Substances: [status]
Occupation: [status]
Living Situation: [status]

REVIEW OF SYSTEMS
-----------------
[Flag: "ROS requires clinician input -- not reliably captured in structured FHIR data"]
[Pre-populate any available Observation category=survey data]

PHYSICAL EXAMINATION
--------------------
Vitals: T [temp] | HR [hr] | RR [rr] | BP [sys]/[dia] | SpO2 [spo2]% | Wt [wt] | Ht [ht] | BMI [bmi]
[Flag: "Physical exam requires clinician input"]
[Pre-populate any Observation category=exam data]

LABORATORY DATA
---------------
[From Step 10, abnormals flagged]

IMAGING
-------
[Search DiagnosticReport if available, otherwise flag as "No imaging data in structured records"]

ASSESSMENT
----------
[Primary admission diagnosis with ICD-10]
[Active problem list from Step 3]

PLAN
----
[Flag: "Plan requires clinician input"]
[Pre-populate from CarePlan if available]

DATA GAPS REQUIRING CLINICIAN INPUT
------------------------------------
- [ ] HPI narrative
- [ ] Review of Systems
- [ ] Physical Examination findings
- [ ] Assessment and Plan details
[Additional gaps identified during assembly]

Step 13: Persist as DocumentReference (if authorized)

code

Tool: fhir_create
resourceType: "DocumentReference"
resource: {
  "resourceType": "DocumentReference",
  "status": "current",
  "type": {
    "coding": [{
      "system": "http://loinc.org",
      "code": "34117-2",
      "display": "History and physical note"
    }]
  },
  "subject": {"reference": "Patient/[patient-id]"},
  "date": "[current-datetime]",
  "author": [{"reference": "Practitioner/[practitioner-id]"}],
  "content": [{
    "attachment": {
      "contentType": "text/plain",
      "data": "[base64-encoded-note]"
    }
  }],
  "context": {
    "encounter": [{"reference": "Encounter/[encounter-id]"}]
  }
}

Examples

Example 1: Admission H&P for CHF Exacerbation

User says: "Generate an H&P for patient 54321, admitted today for CHF exacerbation."

Actions:

•fhir_search Encounter for patient 54321, class=IMP, status=in-progress. Returns ENC-ADM-200, reasonCode="Acute on chronic systolic heart failure exacerbation".
•fhir_read Patient/54321. Returns: Robert Brown, DOB 1948-11-03 (age 75), Male.
•fhir_search Condition active. Returns: CHF (I50.22), HTN (I10), T2DM (E11.9), CKD stage 3 (N18.3), atrial fibrillation (I48.91).
•fhir_search Procedure completed. Returns: CABG x3 (2015), pacemaker insertion (2020).
•fhir_search MedicationRequest active. Returns: furosemide 40mg daily, lisinopril 20mg daily, metoprolol 50mg BID, apixaban 5mg BID, metformin 500mg BID.
•fhir_search AllergyIntolerance. Returns: ACE inhibitor cough (lisinopril documented as tolerated despite class allergy).
•fhir_search FamilyMemberHistory. Returns: Father - MI age 58 (deceased), Mother - T2DM, HTN.
•fhir_search Observation social-history. Returns: Former smoker (quit 2010), alcohol 1-2 drinks/week.
•fhir_search Observation vital-signs. Returns: T 98.4, HR 88 irregular, RR 22, BP 158/92, SpO2 91% on RA, Wt 230 lbs (up 15 lbs from last visit).
•fhir_search Observation laboratory. Returns: BNP 1250, Cr 1.8 (baseline 1.4), K 5.1, Na 133.

Result:

code

HISTORY AND PHYSICAL
====================
Patient: Robert Brown | MRN: MRN-54321 | DOB: 1948-11-03 (Age: 75) | Sex: Male
Admission Date: 2024-03-15 | Admitting Diagnosis: Acute on chronic systolic HF exacerbation

CHIEF COMPLAINT: Heart failure exacerbation

PAST MEDICAL HISTORY
1. Heart failure, chronic systolic (I50.22)
2. Hypertension (I10)
3. Type 2 diabetes mellitus (E11.9)
4. Chronic kidney disease, stage 3 (N18.3)
5. Atrial fibrillation, persistent (I48.91)

PAST SURGICAL HISTORY
1. CABG x3 (2015)
2. Pacemaker insertion (2020)

MEDICATIONS
1. Furosemide 40mg PO daily
2. Lisinopril 20mg PO daily
3. Metoprolol succinate 50mg PO BID
4. Apixaban 5mg PO BID
5. Metformin 500mg PO BID

ALLERGIES
1. ACE inhibitors - Cough (note: lisinopril currently tolerated)

FAMILY HISTORY
Father: MI at age 58 (deceased)
Mother: Type 2 diabetes, hypertension

SOCIAL HISTORY
Tobacco: Former smoker, quit 2010
Alcohol: 1-2 drinks per week

LABORATORY DATA
BNP: 1250 pg/mL [CRITICAL HIGH]
Creatinine: 1.8 mg/dL [HIGH - baseline 1.4]
Potassium: 5.1 mEq/L [HIGH]
Sodium: 133 mEq/L [LOW]

DATA GAPS REQUIRING CLINICIAN INPUT
- [ ] HPI narrative (onset, exacerbating factors, orthopnea, PND, edema)
- [ ] Review of Systems
- [ ] Physical Examination (JVD, lung sounds, edema grading, S3/S4)
- [ ] Assessment and detailed Plan

Example 2: Elective Surgical Admission

User says: "Create H&P for patient pt-777, pre-op admission for total knee replacement."

Actions:

•fhir_search Encounter for pt-777, class=IMP, today. Returns ENC-SURG-50, reasonCode="Right total knee arthroplasty".
•fhir_read Patient/pt-777. Returns: Susan Lee, DOB 1960-04-12 (age 63), Female.
•fhir_search Condition active. Returns: Right knee osteoarthritis (M17.11), HTN controlled (I10), hypothyroidism (E03.9).
•fhir_search Procedure completed. Returns: Left TKA (2021), cholecystectomy (2005), C-section x2.
•fhir_search MedicationRequest active. Returns: amlodipine 5mg daily, levothyroxine 75mcg daily, vitamin D 2000 IU daily.
•fhir_search AllergyIntolerance. Returns: codeine (nausea/vomiting).
•fhir_search Observation vital-signs. Returns: normal vitals.
•fhir_search Observation laboratory. Returns: CBC normal, BMP normal, PT/INR 1.0, type & screen done.

Result: Full H&P with pre-populated PMH, PSH, meds, allergies, labs. Flags: "Physical exam requires clinician input", "Surgical consent verification needed", "Anesthesia clearance status: check DocumentReference".

Troubleshooting

FamilyMemberHistory returns zero resources

•Family history is often not captured as structured FHIR data. Flag as "Family history not available in structured format -- obtain from patient interview."
•Some systems store family history in Observation resources with category=social-history. Check Observation search results for family-related LOINC codes (54114-4 = Family member health history).

Condition resources lack onset dates

•Use recordedDate as a fallback for when the condition was first documented.
•If neither onsetDateTime nor recordedDate exists, present the condition without a date and note "onset unknown."
•Check Condition.evidence for linked Observations that may have dates.

Social history Observations are missing or sparse

•Social history is variably captured across EMR systems. Flag each missing element explicitly in the DATA GAPS section.
•Check for SDOH (Social Determinants of Health) data in Observation with category=sdoh if the FHIR server supports US Core 5.0+.

Related Skills

•soap-note-generator - For outpatient visit documentation
•progress-note-writer - For subsequent daily inpatient notes after the H&P
•discharge-summary-writer - For discharge documentation referencing the admission H&P
•medication-reconciliation - For detailed medication comparison at admission