What should be included when writing a History of Present Illness (HPI)?

From the Guidelines

The History of Present Illness (HPI) should include a comprehensive description of the patient's principal symptoms, their impact on daily function, and relevant medical history, as well as the time course of symptoms and the existence and evolution of other relevant symptoms. When writing an HPI, it is essential to begin with the chief complaint and then detail the onset, duration, location, quality, severity, timing, context, modifying factors, and associated symptoms [ 1 ]. This should include when symptoms first appeared, how they have evolved over time, any precipitating or alleviating factors, and previous treatments attempted with their outcomes.

Some key points to include in the HPI are:

• The patient's principal cognitive and behavioral symptoms
• The impact of symptoms on daily function, interpersonal relationships, and comportment
• The time course of symptoms
• The existence and evolution of other relevant symptoms
• Pertinent medical history and risk factors
• Relevant negative findings that help rule out differential diagnoses
• Recent changes or exacerbations for chronic conditions

It is also crucial to be specific with details such as pain ratings, precise symptom descriptions, and exact timelines [ 1 ]. The HPI should be an interactive exercise in spontaneity, unexpected responses, and nimble redirection, and may involve input from the patient, family members, or close friends, particularly when symptoms are relatively more prominent [ 1 ]. By taking a comprehensive approach to the HPI, clinicians can ensure accurate diagnosis and treatment planning, establish a baseline for monitoring the patient's condition over time, and determine appropriate billing and coding [ 1 ].

From the Research

History of Present Illness (HPI)

When writing a History of Present Illness (HPI), several key elements should be included to ensure a comprehensive understanding of the patient's condition.

• The HPI should include a detailed account of the patient's chief complaint, including the onset, duration, and severity of symptoms 2.
• A chronological sequence of relevant historical risks and known medical events should be documented to generate a series of pre-event probabilities of the most likely disease causing the patient's chief health concern 2.
• The HPI is not just a diagnostic formulation, but also has therapeutic potential, helping patients make cognitive sense of their illness and serving as a vehicle for sharing the affective burden with the physician 3.
• The clinician should convey a sense of safety, sensitivity, affective competence, and cognitive competence when taking the HPI, and join the patient in coprocessing the illness experience 3.

Key Components of HPI

The following components should be included when writing an HPI:

• A clear description of the patient's symptoms, including their onset, duration, and severity
• A detailed account of any relevant medical history, including previous illnesses, injuries, or surgeries
• A list of the patient's current medications and any allergies or sensitivities
• A description of any factors that may be contributing to the patient's condition, such as lifestyle or environmental factors

Importance of HPI in Clinical Practice

The HPI is a crucial component of clinical practice, as it provides essential information for diagnosis, treatment, and management of patients.

• A well-taken HPI can help clinicians identify potential causes of a patient's symptoms and develop an effective treatment plan 4.
• The HPI can also help clinicians identify any potential allergies or sensitivities that may be contributing to the patient's condition, and develop strategies for avoiding or managing these allergies 4, 5.