What to Call the Patient in an HPI
Refer to the patient as "the patient" throughout the History of Present Illness documentation. 1
Standard Terminology in Medical Documentation
Use "the patient" as the standard reference when documenting the HPI in clinical notes, as this maintains professional medical documentation standards consistent with ACC/AHA clinical data standards for ambulatory electronic health records. 1
Avoid using the patient's name repeatedly in the body of the HPI, as this is not standard practice in formal medical documentation and can make notes less readable when reviewed by multiple providers. 1
Third-person narrative format is preferred, where "the patient" serves as the subject of sentences describing symptoms, timeline, and clinical course. 1, 2
Alternative Acceptable References
"He," "she," or appropriate pronouns can be used after initially establishing "the patient" to avoid repetitive phrasing, though "the patient" remains the primary reference. 1
When incorporating informant information, clearly distinguish by stating "per chart review" or "according to family member" to differentiate sources, but still refer to the subject as "the patient." 2, 3
Documentation Best Practices
Begin the HPI with "The patient is a [age]-year-old [gender] who presents with..." as this opening structure is standard across specialties including cardiology, pulmonology, and psychiatry. 1, 4
Maintain consistency throughout the note by using "the patient" uniformly rather than switching between different references, which improves clarity for other providers reviewing the documentation. 1, 2
In verbal presentations, "the patient" is also the standard reference when presenting cases to colleagues, attending physicians, or during handoffs. 5, 6