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

Writing an Effective History of Present Illness (HPI)

The History of Present Illness (HPI) is the cornerstone of medical diagnosis and should be a comprehensive, chronological narrative that captures the patient's symptoms, their evolution, and impact on daily function to guide accurate clinical decision-making. 1

Structure of an Effective HPI

1. Opening Elements

• Chief Complaint: Document the patient's primary concern in their own words
• Source of Information: Note who is providing the history (patient, family member, caregiver) and assess reliability
• Basic Demographics: Include relevant patient identifiers while maintaining privacy

2. Chronological Narrative

• Onset and Duration: When symptoms began and how long they've persisted
• Progression: How symptoms have evolved over time (improved, worsened, fluctuated)
• Characteristics: Specific qualities of symptoms (location, intensity, quality, radiation)
• Aggravating/Alleviating Factors: What makes symptoms better or worse
• Associated Symptoms: Other symptoms occurring alongside the primary complaint

3. Functional Impact

• Document how symptoms affect the patient's daily activities, work, and quality of life
• Include the patient's own description of functional limitations 1

4. Previous Interventions

• Prior treatments attempted (medications, procedures, lifestyle modifications)
• Response to previous interventions
• Prior evaluations for the same or similar complaints

Key Elements to Include

• Timeline: Present information in chronological order to establish clear cause-effect relationships 1
• Patient's Perspective: Include the patient's own words and understanding of their condition 1, 2
• Contextual Factors: Relevant social, environmental, or psychological factors influencing symptoms
• Risk Factors: Document pertinent risk factors for suspected conditions 3

Best Practices

1. Allow Uninterrupted Narrative: Let patients tell their story initially without interruption (most patients will speak for less than 2 minutes) 1

2. Use Open-Ended Questions: Begin with broad questions before narrowing focus

3. Capture Emotional Content: Document the patient's feelings and concerns about their symptoms 1

4. Maintain Chronology: Organize information temporally to reveal patterns and progression 4

5. Be Concise Yet Complete: Include all relevant information while avoiding unnecessary details

6. Document Both Positive and Negative Findings: Include pertinent positive and negative symptoms relevant to the differential diagnosis 5

Common Pitfalls to Avoid

• Premature Interruption: Research shows clinicians often interrupt patients within 22 seconds, potentially missing crucial information 1

• Omitting Patient Perspective: Failing to document the patient's understanding and concerns about their condition

• Disorganized Presentation: Jumping between different time periods or symptoms without clear structure

• Overreliance on Templates: Using checkbox-style documentation that loses the narrative quality 1

• Neglecting Functional Impact: Failing to document how symptoms affect the patient's daily life

Sample HPI Framework

"[Patient identifier] presents with [chief complaint]. Symptoms began [onset timing] and have [progression pattern]. The patient describes the [symptom] as [characteristics] and notes it is worse with [aggravating factors] and better with [alleviating factors]. Associated symptoms include [related symptoms]. These symptoms impact the patient's life by [functional limitations]. Previous treatments have included [interventions] with [response]. Relevant medical/social history includes [pertinent factors]."

By following this structured approach to the HPI, clinicians can gather comprehensive information that supports accurate diagnosis, effective treatment planning, and clear communication among healthcare providers.