Which term is defined as the comprehensive assessment of a patient's medical history and physical examination findings?

• A. ROS
• B. History and Physical
• C. Admission orders
• D. Discharge instructions

Answer: (B)

The main concept is a comprehensive initial evaluation that combines what the patient reports with what the clinician finds on exam. This History and Physical captures the full medical history—reason for visit, past medical history, medications, allergies, social and family history—as well as the physical examination findings, vital signs, and any pertinent observations. Together, it forms the baseline assessment used to guide diagnosis and the subsequent plan of care.

Review of Systems is a structured part of the history that asks about symptoms across body systems, but it alone does not constitute the complete assessment. Admission orders are the immediate instructions given to start care during a hospital admission, and discharge instructions are the guidelines provided when leaving the hospital. Neither describes the full comprehensive evaluation.