Activity Director Basic Practice Test

The initial patient assessment documented in medical records is the History and Physical, abbreviated H&P. This note combines the patient’s history—past illnesses, surgeries, medications, allergies, and relevant family or social factors—with the physical examination findings to establish a baseline for the patient’s health. It guides diagnosis, treatment planning, and handoffs to other team members, and is typically completed at admission or the first evaluation. Other options aren’t standard abbreviations for this comprehensive initial assessment; they don’t reflect the full history-and-exam document used to anchor care.