What components should be included in a comprehensive History of Present Illness (HPI) template?

Components of a Comprehensive History of Present Illness (HPI) Template

A comprehensive History of Present Illness (HPI) template should include the nature of presenting symptoms, onset and chronology, severity, quality, location, duration, context, modifying factors, associated symptoms, and impact on daily function.

Core Components of an HPI Template

1. Chief Complaint and Presenting Symptoms

• Document the patient's exact words describing their primary concern 1
• Record the nature of presenting symptoms (e.g., rhinorrhea, nasal congestion, sneezing for rhinitis) 2
• For cognitive complaints, characterize the nature of symptoms about which there is concern 2

2. Onset and Chronology

• Document when symptoms began (exact date if possible) 2
• Establish the time course of symptoms (sequential order of onset, frequency, tempo) 2
• For chronic conditions, document the approximate date of diagnosis and possible date of initial infection/onset 2
• Note whether symptoms are acute, subacute, or chronic

3. Severity and Progression

• Document the intensity of symptoms using appropriate scales when available
• Note any progression or changes in severity over time
• For weakness complaints, document using objective strength testing such as Medical Research Council scale 1

4. Quality

• Record the specific characteristics of symptoms (e.g., sharp, dull, burning, throbbing)
• Document any unique features or patterns of symptoms

5. Location

• Note the precise location of symptoms
• Document any radiation, spread, or changes in location
• For physical complaints, note whether symptoms are unilateral or bilateral 2

6. Duration and Pattern

• Record how long symptoms last when they occur
• Document any patterns (e.g., intermittent, constant, cyclical, seasonal) 2
• Note any relationship to time of day, activities, or other factors

7. Context and Precipitating Factors

• Document circumstances when symptoms occur
• Record any identifiable triggers or precipitating factors 2
• Explore plausible relationships between events and presenting symptoms 2
• Note any environmental or occupational exposures 2

8. Modifying Factors

• Document what makes symptoms better or worse
• Record any self-treatment attempts and their effectiveness
• Note response to previous treatments, including medications 2

9. Associated Symptoms

• Document any accompanying symptoms
• For specific conditions, include relevant associated symptoms:
  • For weakness: visual disturbances, speech/swallowing difficulties, respiratory symptoms 1
  • For cognitive concerns: behavioral changes, sensorimotor symptoms 2

10. Impact on Function and Quality of Life

• Evaluate impact of symptoms on activities of daily living 2
• Document effects on interpersonal relationships 2
• Assess impact on work/school performance 2
• Note any safety concerns related to symptoms 2
• Document need for caregiver support 2

Additional Important Elements

11. Review of Relevant Systems

• Perform a structured survey of all major domains related to the presenting complaint 2
• For cognitive concerns: assess cognition, daily function, behavior/neuropsychiatric symptoms, and sensorimotor function 2

12. Prior Testing and Treatments

• Document previous diagnostic tests related to the current complaint
• Record prior treatments and their effectiveness 2
• Note any medication side effects or intolerance 2

13. Risk Factors

• Document individualized risk factors relevant to the presenting complaint 2
• Include both modifiable and non-modifiable risk factors

Implementation Considerations

• Use a structured approach to ensure comprehensive data collection 2
• Integrate information from both patient and informant/care partner when appropriate 2
• Consider using standardized instruments for specific domains when available 2
• Document using the patient's own words whenever possible 1
• Avoid medical jargon when recording the patient's description of symptoms

Common Pitfalls to Avoid

• Failing to document the chronological sequence of symptoms
• Neglecting to assess impact on daily function
• Omitting information about prior treatments and their effectiveness
• Not exploring potential triggers or exacerbating factors
• Focusing only on physical symptoms while ignoring psychological aspects
• Using leading questions that may bias the patient's responses
• Relying solely on closed-ended questions that limit the narrative

By following this comprehensive HPI template, clinicians can gather the essential information needed to guide diagnosis and treatment planning while ensuring that all relevant aspects of the patient's experience are documented.