How do I write a History of Present Illness (HPI)?

From the Guidelines

To write an effective History of Present Illness (HPI), start by documenting the chief complaint, followed by a chronological narrative of the patient's symptoms, utilizing the OLDCARTS framework to capture key characteristics, as suggested by 1. When writing an HPI, it is essential to begin with the chief complaint, which is the primary reason the patient is seeking medical attention. This should be followed by a detailed, chronological narrative of the patient's symptoms, including when they first appeared, their severity, and any factors that aggravate or alleviate them. The OLDCARTS framework is a useful tool for ensuring that all relevant information is captured: Onset (when the symptom started), Location (where the symptom is), Duration (how long the symptom has lasted), Characteristics (the quality of the symptom), Aggravating/Alleviating factors (what makes the symptom better or worse), Radiation (if the symptom spreads elsewhere), Timing (patterns or triggers), and Severity (using a scale like 1-10) 1.

Key Components of HPI

• Chief Complaint: A concise statement of the patient's primary concern.
• Chronological Narrative: A detailed description of the patient's symptoms in chronological order.
• OLDCARTS Framework: A mnemonic device to help remember key characteristics of symptoms:
  • Onset
  • Location
  • Duration
  • Characteristics
  • Aggravating/Alleviating factors
  • Radiation
  • Timing
  • Severity
• Relevant Past Medical History: Include any past medical conditions that are directly related to the current complaint.
• Self-Treatment Attempts: Document any self-treatment attempts the patient has made and their effects.
• Impact on Daily Functioning: Describe how the symptoms have affected the patient's daily life and activities.

Best Practices for Writing HPI

• Be specific with details, such as medication dosages and frequencies.
• Include relevant negative findings to help rule out differential diagnoses.
• Keep the narrative concise but comprehensive, typically 3-7 sentences for straightforward cases and longer for complex presentations.
• Use a structured approach to ensure that all clinically relevant information is captured and presented in a clear, logical flow that other healthcare providers can easily follow, as emphasized by 1.

From the Research

Writing a History of Present Illness (HPI)

To write an effective HPI, consider the following key points:

• The HPI is a crucial component of a patient's medical history, as it provides a detailed account of the patient's current illness or condition 2.
• When writing an HPI, it is essential to include the patient's chief complaint, a detailed description of the symptoms, and any relevant medical history 3.
• The use of computer-generated HPIs has been shown to be effective in improving the quality and efficiency of patient care, as they can provide a more comprehensive and organized account of the patient's symptoms 2.
• A study published in the American Journal of Gastroenterology found that computer-generated HPIs were judged to be of higher quality, better organized, and more succinct than HPIs written by physicians 2.

Key Components of an HPI

Some key components to include when writing an HPI are:

• Chief complaint: a brief statement of the patient's primary symptom or concern 4, 5.
• History of present illness: a detailed description of the patient's symptoms, including when they started, how they have progressed, and any factors that exacerbate or relieve them 3.
• Associated symptoms: any other symptoms that the patient is experiencing, such as pain, fatigue, or difficulty breathing 3.
• Medical history: any relevant medical conditions, allergies, or previous illnesses that may be related to the patient's current condition 3.

Best Practices for Writing an HPI

Some best practices to keep in mind when writing an HPI include:

• Using a systematic approach to collect and organize the patient's symptoms and medical history 2.
• Including all relevant information, even if it seems minor or unrelated to the patient's chief complaint 3.
• Using clear and concise language to describe the patient's symptoms and medical history 2.
• Reviewing and updating the HPI regularly to ensure that it remains accurate and comprehensive 2.