What does a history of present illness (HPI) include?

What the History of Present Illness Includes

The History of Present Illness (HPI) is a comprehensive narrative that documents the patient's principal symptoms, their impact on daily function, the time course of symptom evolution, relevant associated symptoms, and pertinent medical history and risk factors. 1

Core Elements of the HPI

The HPI should systematically capture the following components:

Patient's Chief Concern and Narrative

• Begin by asking "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 1
• Allow the patient to describe their symptoms in their own words before integrating other information sources 2
• Document the patient's narrative in sufficient detail to accurately represent their story 3

Symptom Characterization

• Detailed description of the principal cognitive, behavioral, or physical symptoms 1
• Onset and duration of each symptom 1
• The patient's activity and position before symptom onset (particularly important in pediatric cases) 1
• Characteristics of current symptoms, including severity and quality 4

Functional Impact Assessment

• Impact on daily function and activities of daily living 1
• Effects on interpersonal relationships and comportment 1
• Changes in physical activity and sleep behaviors 4

Temporal Evolution

• Time course and progression of symptoms—this is critical for establishing diagnostic probability 1
• Chronological sequencing of relevant historical risks and known medical events 5
• Evolution of associated symptoms over time 1

Informant Information (When Applicable)

• In cases of cognitive or behavioral concerns, informant reports provide added value beyond patient self-report alone 1
• Family member or close friend observations, particularly when the patient has diminished insight 1
• Comparison between patient and informant perspectives when they diverge 1

Additional Historical Context to Include

Past Medical History Elements

• Duration of chronic conditions and dates of diagnosis 3
• Prior negative tests 3
• History of chronic diseases affecting the current presentation (renal disease, lung disease, liver disease, etc.) 3
• For pediatric cases: pregnancy history, prematurity, total parenteral nutrition, hepatobiliary disease 1

Medication and Substance History

• Current prescription medications, over-the-counter drugs, supplements, and herbal remedies 4
• Tobacco, alcohol, and substance use patterns 4
• Medications that can affect bone health or other relevant systems 1

Social and Environmental Factors

• Social determinants of health including food security, housing stability, transportation access, financial security 4
• Existing social supports 4
• Vaccination status 4

Integrating Chart Review Information

Chart review data should complement but not replace direct patient interview 2:

• Clearly distinguish between information obtained from patient/informant interview versus chart review 2
• Include chart review information that establishes previous diagnostic workup, prior treatments and their outcomes 2
• Use chart review to fill gaps in patient recollection and establish clear timelines 2
• Document the source of each piece of information (patient report vs. chart review) 2

Common Pitfalls When Using Chart Review

• Overreliance on chart review may perpetuate previous diagnostic errors—always verify key historical elements directly with the patient 2
• Chart review data may be incomplete or contain inaccuracies; cross-reference from multiple sources 2
• Patients may feel ignored if providers focus excessively on chart review rather than their current narrative 2

Documentation Best Practices

• Document pertinent negatives—important symptoms that are absent 4
• Synthesize all information into a coherent narrative that supports clinical reasoning 2
• Use templates appropriately for standardized elements, but maintain narrative quality for the HPI itself 3
• Avoid copy-pasting entire notes without editing, as this propagates errors and outdated information 3

Special Considerations for Specific Populations

Cognitive or Behavioral Concerns

• Expect unpredictable responses due to diminished insight 1
• Anticipate divergent opinions between patient and care partner 1
• Integrate multiple information sources to characterize symptoms accurately 1

Pediatric Cases

• For nonverbal children, obtain detailed witness account including child's position before and after injury 1
• Interview verbal children apart from caregivers, ideally by forensic interviewing professionals 1
• Obtain thorough dietary history 1

Elderly Patients

• Pay particular attention to functional status, cognitive function, and fall risk 4
• Document surrogate decision maker and advance care plan status 4