Key Elements of the History of Present Illness (HPI) Section
The History of Present Illness (HPI) section should include information about the onset, quality, intensity, distribution, duration, course, sensory and affective components of the presenting complaint, along with exacerbating and relieving factors, and additional symptoms. 1
Essential Components of the HPI
Core Elements
- Chronology of symptoms: Sequential order of onset, frequency, tempo, and nature of change over time 2
- Symptom characteristics: Quality, intensity, location, radiation, duration 1
- Modifying factors: Exacerbating and relieving factors 1
- Associated symptoms: Additional symptoms including motor, sensory, and autonomic changes 1
- Impact assessment: Effects on daily function, work/school performance, and relationships 2
Contextual Information
- Diagnosis history: When, where, why, and how diagnosis was made (for known conditions) 1
- Previous treatments: Results of previous diagnostic tests and therapies 1
- Current therapies: Ongoing treatments and their effectiveness 1
Condition-Specific Elements
For HIV/Infectious Disease Patients
- Date of diagnosis and approximate date of infection 1
- Prior use of antiretroviral therapy or prophylaxis 1
- HIV-related conditions (opportunistic infections, malignancies) 1
- Risk factors and exposure history 1
For Chronic Pain Patients
- Pain history with emphasis on chronology and symptomatology 1
- Effects of pain (physical deconditioning, occupational status changes) 1
- Impact of previous treatments 1
For Cardiac/Heart Failure Patients
- Onset and progression of symptoms 1
- Functional limitations and activity tolerance 1
- Prior cardiac events and interventions 1
Effective Documentation Techniques
Organization Methods
- Present information in chronological order 2
- Use clear, concise language avoiding medical jargon 2
- Include pertinent positives and negatives 2
- Begin with open-ended questions followed by focused inquiries 2
Enhanced Approaches
- Consider using the "All-Inclusive HPI" approach that integrates relevant historical risks with chronologically sequenced medical events 3
- Organize information in a timeline-based format (Chronology of Present Illness) to improve clarity and communication 4
Common Pitfalls to Avoid
- Attributing symptoms to "normal aging" without proper evaluation 2
- Framing history solely around a major event the patient believes is causal 2
- Relying solely on closed-ended questions 2
- Failing to integrate information from informants when appropriate 2
- Neglecting to assess impact of symptoms on daily function 2
- Interrupting the patient's narrative prematurely 2
By incorporating these elements into the HPI section, clinicians can develop a comprehensive understanding of the patient's condition, which serves as the foundation for accurate diagnosis and effective treatment planning.