Comprehensive HPI Template for Texas Wellness Visit
A comprehensive History of Present Illness (HPI) template for a Texas Wellness visit should include medical history, social determinants of health, functional status assessment, preventive care history, and symptom evaluation structured in a systematic format that facilitates thorough documentation and quality care.
Core Medical History Components
Medical History
- Cardiovascular conditions: Document history of coronary artery disease, heart failure, arrhythmias, structural/hemodynamic abnormalities, and cardiovascular procedures 1
- Atherosclerotic risk factors: Include hypertension, hyperlipidemia, diabetes, tobacco use, family history, obesity, diet patterns, physical inactivity, and stress 1
- Comorbid conditions:
- Associated with increased CVD risk: diabetes, peripheral arterial disease, cerebrovascular disease, chronic kidney disease, sleep apnea
- Other significant conditions: pulmonary disease, gastrointestinal disorders, musculoskeletal disorders, cancer, depression, cognitive impairment 1
- Current symptoms: Document onset, quality, intensity, distribution, duration, course, and sensory/affective components 2
- Medication review: List all prescription and non-prescription medications, supplements with dosages, frequency, and adherence patterns 1
- Vaccination status: Document influenza, pneumococcal, COVID-19, and other relevant immunizations with dates 1
Social Determinants of Health
- Living situation: Document marital status, who patient lives with, home environment characteristics (house/apartment, stairs) 1
- Social support structure: Identify spouse/partner, children, other family or community members providing support 1
- Health literacy and education: Assess understanding of health information and educational background 1
- Employment status: Document current work situation, work history, and occupational exposures 2
- Financial concerns: Note medication access/affordability and ability to obtain medical care 1
- Transportation access: Document availability of transportation for medical appointments and daily needs 1
Functional Assessment
- Activities of daily living: Assess self-care abilities (bathing, dressing, toileting, transferring, continence, feeding) 2
- Instrumental activities: Evaluate ability to use telephone, shop, prepare food, handle finances, manage medications 2
- Physical activity patterns: Document extent of daily activity, sedentariness, and intentional exercise 1
- Fall risk assessment: Note history of falls, fear of falling, balance issues 1
- Cognitive function: Document any memory concerns, confusion, or cognitive changes 2
- Mental health status: Assess for depression, anxiety, or other mental health conditions 2
Health Behaviors
- Dietary patterns: Document typical eating habits, who does shopping/cooking, frequency of dining out 1
- Sleep patterns: Assess sleep quantity, quality, and any sleep disturbances 1
- Substance use: Document alcohol consumption, tobacco/vaping use, and other substance use 1
- Preventive care history: Record screenings (cancer, cardiovascular), last physical exam, dental visits 2
Symptom-Specific Assessment
- Cardiovascular symptoms: Document chest pain, palpitations, irregular heartbeat, dyspnea, orthopnea, edema 1
- Respiratory symptoms: Note cough, wheezing, shortness of breath, exercise tolerance 1
- Neurological symptoms: Document headaches, dizziness, syncope, sensory changes 1
- Musculoskeletal symptoms: Assess pain, stiffness, mobility limitations 1
- Gastrointestinal symptoms: Note changes in appetite, weight, bowel habits 2
Documentation Best Practices
- Begin with open-ended questions to allow patients to tell their story, followed by focused questions for clarification 2
- Present information in chronological order using clear, concise language 2
- Include pertinent positive and negative findings 2
- Avoid attributing symptoms to "normal aging" without proper evaluation 2
- Document impact of any symptoms on daily function and quality of life 2
Implementation Tips
- Use structured instruments for assessing specific domains when appropriate 2
- Consider digital tools to collect HPI information before the visit to improve efficiency 3, 4
- Focus documentation on the most clinically relevant sections (HPI, Assessment, Plan) that physicians identify as most important 5
- Ensure documentation supports preventive care needs specific to Texas wellness requirements
Common Pitfalls to Avoid
- Relying solely on closed-ended questions that may miss important details 2
- Failing to integrate information from family members or caregivers 2
- Neglecting to assess the impact of symptoms on daily function 2
- Interrupting the patient's narrative prematurely 2
- Not exploring the patient's understanding and concerns about their condition 2
By following this comprehensive template, providers can ensure thorough documentation for Texas Wellness visits while focusing on elements that most directly impact patient morbidity, mortality, and quality of life.