What should be included when documenting the History of Presenting Illness (HPI) in SOAP (Subjective, Objective, Assessment, Plan) notes?

Comprehensive Documentation of History of Presenting Illness (HPI) in SOAP Notes

The History of Presenting Illness (HPI) should include a structured narrative account of the patient's principal symptoms, their chronology, impact on daily function, and relevant risk factors, integrating information from both patient and informants when appropriate. 1

Essential Components of HPI Documentation

Symptom Characterization

• Document the nature of presenting symptoms with specific details 1
• Record when symptoms began (exact date if possible) 1
• Establish the time course of symptoms (sequential order of onset, frequency, tempo, and nature of change over time) 2
• Note the precise location of symptoms and any radiation or spread 1
• Describe the character of symptoms (e.g., sharp, dull, burning) 1
• Document intensity using appropriate scales when relevant 1
• Record duration of symptoms and circumstances when they occur 1
• Identify any triggers or exacerbating/relieving factors 1

Functional Impact Assessment

• Evaluate impact on activities of daily living (ADLs and instrumental ADLs) 2
• Assess impact on work/school performance 1
• Document effects on interpersonal relationships 2, 1
• Note any safety concerns related to symptoms 2, 1
• Assess need for care partner support 2

Contextual Information

• Explore plausible relationships between events and the presenting symptoms 2
• Document potential triggers or contextual features 2
• Record any previous history of similar symptoms 1
• Note all medications taken (including over-the-counter and complementary therapies) 1
• Document any previous history of allergies or similar reactions 1

Domain-Specific Assessment

• For cognitive/behavioral symptoms: document changes in cognition, daily function, mood/behavior, and sensorimotor function 2
• For pain: document onset, quality, intensity, distribution, duration, course, and sensory/affective components 1
• For infectious diseases: document travel history, exposure risks, and immunization status 2
• For skin conditions: document specific manifestations, extent, and distribution of lesions 1

Interviewing Techniques

• Begin with open-ended questions to allow patients to tell their story 1
• Follow with focused questions to clarify specific aspects of the history 1
• Avoid interrupting the patient's narrative prematurely 1
• Clarify medical terminology that patients may misuse 1
• Integrate information from both patient and informant/care partner when appropriate 2, 1
• Use structured instruments for assessing domains when appropriate 2

Presentation Format

• Present information in chronological order 1
• Use clear, concise language 1
• Avoid medical jargon when documenting patient's descriptions 1
• Include pertinent positives and negatives 1
• Consider using a timeline-based format (Chronology of Present Illness) to improve clarity 3

Common Pitfalls to Avoid

• Attributing symptoms to "normal aging" without proper evaluation 1
• Framing history solely around a major event that patient believes is causal 1
• Relying solely on closed-ended questions 1
• Failing to integrate information from informants when needed 2, 1
• Neglecting to assess the impact of symptoms on daily function 2, 1
• Interrupting the patient's narrative prematurely 1
• Not exploring the patient's understanding and concerns about their condition 1

Special Considerations

• For patients with cognitive impairment: obtain information from a reliable informant 2
• For patients with language barriers: use appropriate interpretation services
• For patients with complex presentations: consider using structured assessment tools 2
• For patients with travel history: document locations visited, dates of travel, dates of symptom onset, and risk activities undertaken 2

By following this comprehensive approach to documenting the HPI, clinicians can improve diagnostic accuracy, enhance patient-physician communication, and provide a solid foundation for the assessment and plan portions of the SOAP note.