What should a good History of Present Illness (HPI) contain?

What Should a Good History of Present Illness (HPI) Contain

A comprehensive HPI should include a chronological narrative of the patient's chief complaint with symptom characteristics, relevant medical history, medication regimen, social determinants of health, and safety assessment, organized in a timeline-based format that facilitates diagnostic reasoning. 1, 2, 3

Essential Core Components

Patient Demographics and Context

• Document age, gender, and date of last visit to establish baseline context 1
• Record changes in medical and family history since the last encounter, focusing on elements relevant to the current presentation 1, 3
• Include living situation, self-care abilities, and functional status as these provide critical context for treatment planning 2

Symptom Characterization

• Describe the chief complaint using a chronological, timeline-based approach that sequences relevant historical risks and known medical events to generate pre-event probabilities of likely diagnoses 4, 5
• Document all major symptom domains systematically: cognition, mood, psychosis (if applicable), anxiety, and impact on daily functioning 2
• Include pertinent negatives—important symptoms that are absent—as failing to document these leads to incomplete assessment 1

Medication and Treatment History

• Record current medication regimen comprehensively: prescription drugs, over-the-counter medications, supplements, and herbal remedies 1
• Document medication adherence, side effects, and response to treatment in detail 2
• Note previous treatments attempted and their outcomes from chart review when relevant 3

Behavioral and Social Assessment

• Evaluate physical activity, sleep behaviors, and screen for sleep apnea 1
• Document tobacco, alcohol, and substance use patterns 1
• Assess social determinants of health: food security, housing stability, transportation access, financial security, and community safety 1
• Identify existing social supports and surrogate decision maker status 1

Safety and Risk Assessment

• Conduct a structured safety assessment with specific details about suicidal or homicidal ideation when clinically indicated 2
• Review safety plans with patients who have psychiatric concerns 2

Organizational Structure

Timeline-Based Format

• Begin with the patient's own narrative of current symptoms, then integrate relevant chart review information to establish a clear timeline and progression 3, 5
• Chronologically sequence both relevant historical risks and known medical events to improve diagnostic reasoning 4
• Use chart review to fill gaps in the patient's recollection, but clearly distinguish between information obtained directly from the patient versus from documentation 3

Integration of Multiple Sources

• Synthesize information from patient interview, informant reports, and prior documentation into a coherent narrative 3
• Cross-reference information from multiple sources to verify key historical elements and avoid perpetuating previous diagnostic errors 3
• Clearly document the source of each piece of information (patient report vs. chart review) 3

Disease-Specific Considerations

Cardiovascular Assessment (When Relevant)

• Document history of cardiovascular disease, cerebrovascular disease, or stroke 1
• Record most recent LDL and HDL measurements 1
• Note family history of premature coronary artery disease or sudden cardiac death 6

Chronic Disease Management (When Applicable)

• Review disease history including characteristics at onset and previous treatment plans 1
• Document family history of relevant conditions in first-degree relatives 1
• Assess for common comorbidities specific to the patient's condition 1

Occupational and Environmental Exposures

• Use a structured, clinically relevant environmental and occupational questionnaire adapted to regional geography and customs when exposure-related disease is suspected 6
• Consider consultation with occupational medicine specialists if the inciting antigen is thought to be occupational 6

Preventive Care Documentation

• Record vaccination status according to age-appropriate recommendations 1
• Document screening status for sexually transmitted diseases if indicated 1
• Note status of recommended cancer screenings 1
• Include cognitive and functional performance assessments, particularly for elderly patients 1
• Document depression and anxiety screening results 1

Common Pitfalls to Avoid

• Avoid overreliance on chart review that may perpetuate diagnostic errors; always verify key elements directly with the patient 3
• Do not allow patients to feel their narrative is being ignored; let them tell their story in their own words before integrating chart review information 3
• Failing to address social determinants of health may miss critical factors affecting patient outcomes 1
• Including excessive chart review details makes the HPI unwieldy; be selective and include only information relevant to the current presentation 3
• Not documenting the rationale for treatment decisions undermines the clinical reasoning process 2

Quality Characteristics

A well-constructed HPI should be thorough, well-organized, succinct, comprehensible, and useful for clinical decision-making 7. Research demonstrates that structured, timeline-based formats improve efficiency, clarity of communication, and diagnostic reasoning compared to unstructured approaches 5. The HPI serves as the cornerstone of medical diagnosis, providing a narrative account that facilitates accurate inference of the correct diagnosis 4, 8.