The Whole Health Note: Beyond the Standard History and Physical
- The History and Physical (H&P) examination remains a way of gathering information when you do a Whole Health Assessment, but in some ways, it is broadened as you focus more on a Veteran’s values and self-care, and use a team-based approach.
- Each section of the H&P expands to include additional questions and details that can take patient encounters in new directions.
The H&P examination forms the backbone of a medical visit. When you use the Whole Health Approach, it remains important, as part of the Whole Health Assessment. However, as the conversation expands, you might note that in some ways, your H&P changes too. Some examples are as follows:
- As you cover the different areas of the Circle of Health over time, you will learn more about your patients’ lives than you knew before—their strengths, struggles, dreams, and unique stories. A yearly visit can seem like an opportunity to catch up with an old friend.
- You may find that you focus more on prevention than before, especially as it relates to empowering Veterans to do self-care.
- You will likely remember information from visits more clearly. If you move beyond “just the facts” to the realm of narrative, documentation becomes more of an exercise in “telling the story.” Humans are better at remembering stories than lists of facts. You become more invested in the outcome, when you know what their goals and aspirations are, as opposed to just knowing their problems.
In medical training, we were taught to let the outline for the H&P be our anchor as we have conversations with patients. For Whole Health visits, it still can be, but there are ways to elaborate on it.
What follows is a breakdown of how the parts of the H&P can change, section by section, during a Whole Health visit. As you review, ask yourself how you would organize a Whole Health H&P with your own patients. Of course, leave room for spontaneity, but it is helpful to have a general template in mind.
- Especially in visits for chronic conditions, take the focus beyond what is wrong. A person need not have a “complaint” or a “problem” in order to have an effective Whole Health visit.
- Skills, positive attributes, and what is “right” can also guide the conversation. It can help to highlight what your patient does well, such as skills, positive attributes, past successes, places where they rate themselves highly in the Personal Health Inventory (PHI). Then have them use these “superpowers” to create their Personal Health Plans (PHPs).
- Right away, clarify a person’s agenda for their visit as well as the agendas of anyone who is there with them. Make goals for the visit explicit right away, so there will not be any surprises when you have your hand on the door, ready to leave.
- Remember, someone’s problems or challenges may inform what is discussed, but they should not drive the entire visit. Instead, focus on possibilities, and on how you can empower people to do more to take care of themselves. It is especially important to remember this when chronic pain comes up; you can end up focusing on how bad the pain is for the entire conversation, which doesn’t serve a person very well.
- Rather than “Chief Complaint,” this section of the H&P might be titled “Goals for Today.”
History of Present Illness
- A person’s mission statement (e.g. “I want to be able to stay active for as long as I can” or “I want to travel to see my family in France one final time before I die”) may inform what you ask as you generate the HPI. What has helped them achieve their goals in the past? What do they need now? What are their strengths and challenges?
- While data about an illness or problem is important, especially if a diagnosis is yet to be made, questions should also delve into a person’s story, into what makes him or her unique. Narrative medicine can be a useful tool for this. (Refer to “A Quick Guide to Using Narrative Medicine in a Busy Practice” and “Exercise and Readings for Narrative Medicine Groups” for more information.)
- Give attention to individual diagnoses as needed, but do not get sidetracked or overwhelmed by trying to focus on multiple diagnoses in one visit at the expense of a deeper conversation. If possible, seek out root causes that if addressed, might favorably affect multiple diagnoses at the same time. For example, helping someone focus on Food and Drink could favorably affect obesity, nighttime binge eating, hypertension, sleep apnea, insulin resistance, depression, and joint pain all at once.
Past Medical and Surgical History
- Move beyond simply listing past events to exploring their impact on a person’s day-to-day life. How are activities of daily living affective? What about the ability to do what they enjoy? Their self-perception?
- What is the story behind a given diagnosis? How does this story fit into their overall life story? How much insight do they have about the causes of their health issues?
- Ask what Complementary and Integrative Health (CIH) therapies have they tried in the past? Are there any they are currently using? What diagnoses did CIH practitioners give them?
- Review medications, but also take over-the-counter products and dietary supplements into account. Work closely with your team’s pharmacist, if possible.
- Consider supplement-drug interactions and ask about why someone chose to take the supplements they are taking. (Refer to Chapter 15 “Biologically-Based Approaches: Dietary Supplements” in the Passport to Whole Health for additional information.) This can be an opportunity to educate about supplement use.
- Ask patients how they do with remembering to take their medications (and supplements). Are they taking them as prescribed? If not, explore why.
- Consider asking about more than drug allergies, which are usually the focus. Inquire about environmental and dietary allergies/intolerances. How do work and home environments affect their health? (Refer to “Surroundings” and related Whole Health tools for more information.)
- Perhaps this section of the H&P expands the most when the PHI is used to gather information. All of the following topics, among many others, could be wrapped into the social history:
- Experiences with mindful awareness
- Stress levels and tools used to cope
- Physical activity patterns
- Past experience with CIH modalities
- Key relationships and social affiliations
- Dietary patterns
- Environment (work, home, physical, and emotional)
- Unhelpful behaviors in general (tobacco, alcohol, caffeine, binge eating, etc.)
- Perspectives regarding spirituality
- Goals, talents, and skills
- Groups they belong to, including support groups and classes
- In addition to listing family members’ illnesses and causes of death, it is important to learn who is considered a person’s family. Sometimes, this may mean members of a “family of choice,” not family of origin. Do they have a living will and a durable power of attorney?
- Ask about traumatic experiences and abuse. How was it for them to grow up? Early life trauma can be another important “root cause” of many different illnesses or symptoms. It is striking how often some form of abuse or trauma will come up during a Whole Health visit, if a patient is given time to share.
REVIEW OF SYSTEMS
- Notes may be organized according to different body systems, but it is possible to view patients from other, less reductionist perspectives as well. A patient’s mission, self-care practices, and life story are all sources of potentially valuable details that are not necessarily captured in a standard review of systems
- Refer to the Boston VA’s “Whole Health Review of Systems” intake form for one example.
- Do an exam, as appropriate.However, especially when working with chronic illness, you may choose to shorten or eliminate it in some encounters to allow for more time to gather subjective data or to create the PHP.
- Keep in mind, however, that touch can be a powerful healer in and of itself.
- Consider summarizing at the end of a visit, and invite the patient to weigh in on the accuracy of the information you have gathered.
- It may be helpful to work the person’s mission, aspiration, purpose (MAP) into the summary that you do. For instance, instead of “68-year-old man with multiple chronic diagnoses presents for…” you could add in a few more details, such as “72-year-old Vietnam Air Force Veteran and retired mechanic who just celebrated his 60thwedding anniversary, here today for…”
- Organize both the Assessment and the Plan in your note based on the components of the Circle of Health, rather than basing it on diagnoses.
- The PHP is co-authored with the patient and his/her family.
- A PHP offers specific recommendations for the patient. It is typically more extensive than a standard plan in an H&P, in that it is likely to cover not only professional care, but also detailed goals related to self-care. Refer to the sample of the plan in the overview, “Implementing Whole Health in Your Practice, Part I: What a Whole Health Visit Looks Like.”
- The plan may arise through any number of approaches, ranging from setting SMART (Specific, Measurable, Action-Oriented, Realistic, and Timed) goals, using Motivational Interviewing, or simply picking an area of the Circle of Health and deciding to make one small change. It may be that as a clinician, you will be elaborating on a PHP that a Veteran has already started working on with a Whole Health Coach or a Whole Health Partner. No two PHPs will ever be alike, even if two people have exactly the same problem list.
- You will likely have additional topics or items you wish to add to those listed above. The Brief Personal Health Plan Template and the Long Personal Health Plan Template can serve a basis for developing plans of your own. Experiment! Try out different approaches, and find the Whole Health H&P style that works for you. Escape from the “Find it, Fix It” model, and make your connections with Veterans richer in the process.
“The Whole Health Note: Beyond the Standard History and Physical” was written by J. Adam Rindfleisch, MPhil, MD, (2014, updated 2017).
This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation