Emergency Room HPI Documentation Template
The most effective HPI documentation in the emergency room setting should follow a structured, comprehensive template that captures all essential clinical elements while maintaining efficiency and clarity. 1
Core HPI Template
Patient is a [age]-year-old [gender] who presents to the emergency department with chief complaint of [specific complaint]. Symptoms began [onset: sudden/gradual] approximately [time frame] ago. The patient describes the [pain/symptoms] as [quality: sharp/dull/burning/throbbing/pressure/etc.]. On a scale of 1-10, patient rates the [pain/discomfort] as [severity]. The [pain/symptoms] is located in/at [location] and [does/does not] radiate to [location].
Associated Symptoms
Patient [reports/denies] associated symptoms including:
- [List positive findings]
- [List pertinent negative findings]
Aggravating/Alleviating Factors
The [pain/symptoms] is made worse by [aggravating factors] and improved with [alleviating factors]. Patient [has/has not] tried [home remedies/medications] with [effect].
Temporal Pattern
Since onset, symptoms have [improved/worsened/remained unchanged]. The pattern has been [constant/intermittent/waxing and waning].
Relevant History
- Past Medical History: [relevant conditions]
- Past Surgical History: [relevant procedures]
- Medications: [current medications with dosages]
- Allergies: [medication allergies and reactions]
- Social History: [relevant social factors including substance use]
- Family History: [relevant family history]
Review of Systems
Pertinent positives: [list] Pertinent negatives: [list]
Vital Signs
Temperature: [°F/°C] Heart rate: [bpm] Respiratory rate: [breaths/min] Blood pressure: [mmHg] Oxygen saturation: [%] on [room air/oxygen delivery method] Pain score: [0-10 scale]
Condition-Specific Elements
For Trauma Patients
Mechanism of injury: [description] Loss of consciousness: [yes/no, duration] Use of protective devices: [seatbelt/helmet/etc.] Alcohol/substance involvement: [yes/no, details]
For Cardiac Complaints
Character of chest pain: [description] Duration: [time] Radiation: [locations] Associated symptoms: [diaphoresis/nausea/dyspnea/etc.] Risk factors: [hypertension/hyperlipidemia/diabetes/smoking/family history] Previous cardiac history: [MI/stents/CABG/etc.]
For Respiratory Complaints
Onset and progression: [description] Associated symptoms: [fever/cough/sputum production/hemoptysis] Exertional capacity: [description] History of asthma/COPD/other respiratory conditions: [details] Smoking history: [pack-years]
For Neurological Complaints
Time of onset: [exact time if possible] Progression of symptoms: [description] Focal deficits: [weakness/numbness/speech changes/visual changes] Headache characteristics: [if applicable] History of similar episodes: [details]
Documentation Best Practices
- Be concise but thorough - Include all relevant information without unnecessary repetition 1
- Use chronological order - Present the history in a timeline-based format to improve clarity 2
- Document pertinent positives and negatives - Include both present and absent symptoms that are relevant to the differential diagnosis 3
- Avoid copy/paste errors - While templates are helpful, ensure all information is accurate for the current patient 1
- Include level of consciousness - Document using AVPU or GCS scoring when appropriate 1
- Record vital signs - Include complete vital signs at presentation 1
Common Pitfalls to Avoid
- Failing to document exact time of symptom onset (especially critical for stroke/cardiac cases)
- Omitting medication allergies and current medications
- Not specifying pain characteristics completely
- Overlooking social and environmental factors that may impact care decisions 3
- Using vague descriptors instead of specific measurements or scales
- Neglecting to document the patient's response to interventions already attempted
By using this structured approach to HPI documentation, emergency physicians can ensure comprehensive, efficient, and medically accurate records that support both clinical care and appropriate coding requirements.