How do you create a History of Present Illness (HPI)?

How to Create a History of Present Illness (HPI)

Begin with the patient's own narrative of their current symptoms, then systematically integrate relevant chart review information to establish a clear timeline and progression, using a structured approach that includes onset, duration, severity, characteristics, modifying factors, associated symptoms, functional impact, and relevant risk factors. 1, 2

Essential Components of the HPI

Core Symptom Characterization

• Document specific descriptions of primary symptoms rather than vague terms, including the nature, quality, and precise characteristics of each complaint 2
• Establish temporal factors including exact onset date/time, frequency of occurrence, duration of episodes, and any progression or changes over time 2
• Quantify severity using appropriate scales or descriptors to establish a baseline for future comparison and monitoring 2

Contextual and Modifying Factors

• Explore relationships between symptoms and triggers, including what exacerbates symptoms, what alleviates them, and any temporal patterns (time of day, relationship to activities, etc.) 2
• Document previous treatments attempted, including self-treatments, prescribed medications, and their effectiveness or lack thereof 2
• Include relevant negatives that help rule out differential diagnoses in your clinical reasoning 2

Functional and Quality of Life Impact

• Evaluate how symptoms affect activities of daily living, functional status at home and work, interpersonal relationships, and overall quality of life 2
• Provide specific examples of how symptoms manifest in the patient's daily life rather than general statements 2

Integrating Chart Review Information

Best Practices for Chart Integration

• Clearly distinguish between information obtained directly from the patient versus chart review by explicitly stating the source (e.g., "Per prior records..." or "Patient reports...") 1
• Focus on chart review information that is relevant to the current presentation, including previous diagnostic workup results, prior treatments and their outcomes, and documented objective findings the patient may not recall 1
• Use chart review to fill gaps in the patient's recollection and establish a clear timeline of disease progression 1

Avoiding Chart Review Pitfalls

• Verify key historical elements directly with the patient to avoid perpetuating previous diagnostic errors from overreliance on chart documentation 1
• Cross-reference information from multiple sources when possible, as chart review data may be incomplete or contain inaccuracies 1
• Allow patients to tell their story in their own words first before integrating chart review information, so patients don't feel their narrative is being ignored 1

Domain-Specific Considerations

For Psychiatric Follow-up Appointments

• Document current medication regimen including doses, adherence, side effects, and response to treatment 3
• Clearly describe psychiatric symptoms including hallucinations, paranoid ideation, mood symptoms, anxiety, and cognitive changes 3
• Note living situation, self-care abilities, and impact of symptoms on daily functioning 3
• Include a safety assessment with specific details about suicidal or homicidal ideation, and document review of the safety plan 3
• Document changes in symptoms or functioning since the previous appointment to monitor treatment effectiveness 3

For Cardiovascular Complaints

• Include details about dyspnea characteristics (exertional vs. rest, orthopnea, paroxysmal nocturnal dyspnea), chest pain characteristics (quality, radiation, duration, precipitating factors), and associated symptoms (diaphoresis, nausea, palpitations) 2
• Document cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, smoking history, and family history 2

For Neurological/Cognitive Complaints

• Incorporate information from both patient and informant/care partner to ensure accuracy, especially for cognitive or behavioral symptoms 2
• Document changes in cognition (memory, language, executive function), daily functioning, mood/behavior, and sensorimotor function 2

For Gastrointestinal Complaints

• Document stool characteristics (consistency, color, presence of blood/mucus), frequency, associated symptoms (nausea, vomiting, abdominal pain), and signs of volume depletion 2

Organizational Structure: The Chronological Approach

Timeline-Based Organization

• Organize the HPI chronologically by sequencing relevant historical risks and known medical events in temporal order, which generates a series of pre-event probabilities of the most likely disease causing the patient's chief complaint 4, 5
• This chronological structure improves diagnostic reasoning by allowing you to track disease progression and identify temporal relationships between exposures, risk factors, and symptom development 5
• The timeline approach enhances verbal case presentations by providing a clear, logical flow that other providers can easily follow 5

Synthesizing Information

• Synthesize all information into a coherent narrative that supports your clinical reasoning and leads logically to your assessment 1
• Conclude with a clear summary of the primary concerns and their impact on the patient 2

Common Pitfalls to Avoid

• Overlooking functional impact leads to missed diagnostic opportunities, as the effect of symptoms on daily activities provides crucial context for treatment decisions 2
• Neglecting modifying factors results in missed diagnostic clues, since information about what improves or worsens symptoms offers important insights 2
• Missing relevant risk factors leads to inaccurate diagnosis and management, making individualized risk assessment essential 2
• Using vague terminology instead of specific symptom descriptions reduces diagnostic accuracy 2

Efficiency Considerations

• Consider using structured questionnaires adapted to regional and local geography to ensure consistency, optimize patient recall, and improve sensitivity for detecting relevant exposures or symptoms 6
• The structured, chronological approach improves overall efficiency of the clinical encounter by allowing focused questioning on areas needing clarification 5
• Computer-generated HPIs using systematic symptom collection have been shown to be more complete, useful, organized, succinct, and comprehensible than physician-documented HPIs in usual care 7