Example of a History of Present Illness (HPI) in SOAP Note Format
The History of Present Illness (HPI) 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
A well-structured HPI includes the following essential elements:
Patient Identification and Chief Complaint
- Patient's basic demographics (age, gender, race/ethnicity)
- Chief complaint in patient's own words
- Source of information (patient, family member, medical records)
Chronological Narrative
- Onset and duration of symptoms
- Progression pattern (sudden, gradual, intermittent, constant)
- Characteristics of symptoms (quality, quantity, severity)
- Aggravating and alleviating factors
- Associated symptoms
- Functional limitations and impact on daily activities
- Prior treatments and responses
Sample HPI in SOAP Format
Subjective (HPI Example):
Mr. John Smith is a 49-year-old white male who presents with "shortness of breath and fever" for the past 6 weeks. The patient reports that his symptoms began gradually with a dry cough that has now become productive with yellow-green sputum. He describes his shortness of breath as worsening with exertion and now occurring at rest. The patient rates his dyspnea as 7/10 in severity, up from 3/10 when symptoms first began. He reports intermittent fevers up to 38.5°C, typically occurring in the evenings and associated with night sweats. The patient also notes an unintended weight loss of approximately 10 pounds over the past 2 months.
The patient was evaluated by his primary care physician 4 weeks ago and prescribed a 10-day course of amoxicillin, which he completed without improvement in symptoms. He denies hemoptysis, chest pain, palpitations, or syncope. His shortness of breath is exacerbated by climbing stairs and walking more than half a block, and is somewhat relieved by rest and sitting upright. The patient reports that his symptoms have significantly impacted his ability to perform his job as a construction worker and he has been unable to work for the past 2 weeks.
Past medical history is significant for hypertension (diagnosed 5 years ago, controlled on lisinopril), type 2 diabetes mellitus (diagnosed 3 years ago, managed with metformin), and osteoporosis (diagnosed 1 year ago, on alendronate). He reports chewing 2 packs of tobacco daily for 30 years, occasional alcohol use (2-3 beers per week), and denies smoking or illicit drug use. He has no known drug allergies. The patient recently traveled to Florida 10 days ago. Family history is noncontributory.
Common Pitfalls to Avoid in HPI Documentation
- Disorganized presentation of symptoms and timeline
- Omitting the patient's perspective on their illness
- Overreliance on templates without customization
- Neglecting to document functional impact of symptoms
- Failing to include relevant negative findings
- Incomplete documentation of prior treatments and responses 1
Best Practices for HPI Documentation
- Use a structured, timeline-based format to improve clarity and diagnostic reasoning 2
- Ensure chronological sequencing of both relevant historical risks and known medical events 3
- Include all pertinent information while maintaining conciseness
- Document the patient's own words when describing symptoms
- Include relevant environmental and occupational exposures using structured questionnaires when appropriate 4
- Maintain a logical flow that facilitates clinical decision-making
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 1.