What should be included when writing a History of Present Illness (HPI) for a patient presenting to the clinic to receive a flu (influenza) shot?

Writing an HPI for a Flu Shot Visit

For a patient presenting solely to receive a flu shot, the HPI should be brief and focused on screening for contraindications and precautions rather than documenting a traditional illness narrative.

Essential Components to Document

Chief Complaint

• Document the patient's stated reason for visit: "Patient presents for seasonal influenza vaccination" 1

Screening for Absolute Contraindications

Your HPI must explicitly address whether the patient has:

• History of severe allergic reaction (anaphylaxis) to any component of the specific vaccine type being administered or to any previous influenza vaccine 1, 2
• For LAIV4 (nasal spray) specifically: concomitant aspirin or salicylate therapy in children/adolescents, asthma diagnosis or wheezing in children aged 2-4 years, immunocompromised status, pregnancy, or receipt of influenza antivirals within 48 hours 1, 2

Screening for Precautions

Document the presence or absence of:

• Current moderate or severe acute illness with or without fever 1, 2
• History of Guillain-Barré syndrome within 6 weeks of previous influenza vaccination 1, 2
• For LAIV4: asthma in persons ≥5 years, or chronic medical conditions (pulmonary, cardiovascular except isolated hypertension, renal, hepatic, neurologic, hematologic, or metabolic disorders including diabetes) 1, 2

Egg Allergy Status (If Using Egg-Based Vaccine)

• Document any history of egg allergy and its severity 1, 2
• Note: Egg allergy of any severity is not a contraindication to vaccination, but severe reactions (angioedema, respiratory distress, recurrent emesis, or requiring epinephrine) require administration in a supervised medical setting 1, 2

Sample HPI Structure

"Patient presents for seasonal influenza vaccination. Denies history of severe allergic reactions to influenza vaccines or vaccine components. Denies history of Guillain-Barré syndrome. No current acute illness. [If applicable: Reports egg allergy with hives only/denies egg allergy]. No contraindications or precautions identified for [specify vaccine type]." 1, 2

Common Pitfalls to Avoid

• Do not write a lengthy narrative about the patient's general health unless it relates to contraindications or precautions 1
• Do not omit documentation of screening for contraindications—this is medicolegally important and demonstrates appropriate pre-vaccination assessment 2, 3
• Do not assume all influenza vaccines are interchangeable for patients with previous reactions; document the specific vaccine type being administered 2

Additional Documentation for Special Circumstances

If the patient has a positive screen for any contraindication or precaution:

• Document the specific finding and your clinical decision-making 2
• For precautions (not contraindications), document why you proceeded with vaccination or chose to defer 1
• For severe egg allergy with egg-based vaccines, document that vaccination is occurring in an appropriate supervised setting 1, 2