Do you write a History of Present Illness (HPI)?

Writing the History of Present Illness (HPI)

Yes, clinicians should write a comprehensive History of Present Illness as it is the cornerstone of medical diagnosis and can identify up to 80% of medical conditions when done thoroughly. 1, 2

Core Purpose and Structure

The HPI serves as the foundation of diagnostic reasoning and must be systematically documented for every patient encounter. 1 The interview should begin with an open-ended question asking patients to describe their chief concern in their own words, then integrate relevant information from chart review to establish a complete clinical picture. 1, 3

Essential Components to Document

Begin with the patient's narrative, then systematically capture:

• Primary symptoms: Onset, frequency, tempo, nature of change over time, and temporal relationships between events 1, 4
• Functional impact: Effects on basic activities of daily living (bathing, dressing, eating, toileting, transferring) and instrumental activities (managing finances, medications, transportation, shopping, meal preparation, housework) 1, 4
• Associated symptoms: All relevant symptom domains including cognition, mood, anxiety, and pertinent negatives (important symptoms that are absent) 5
• Prior treatments: Previous therapies attempted and their outcomes, including medication adherence, side effects, and response 5, 4
• Comprehensive medication list: All prescription drugs, over-the-counter medications, supplements, herbal remedies, and allergies 5, 4

Integrating Chart Review Information

Chart review should complement, not replace, direct patient interview. 3 Include prior diagnostic findings, previous treatment outcomes, and documented objective findings that patients may not recall, but clearly distinguish between information obtained directly from the patient versus from documentation. 5, 3 This approach reduces the likelihood of missing important historical details while avoiding perpetuation of previous diagnostic errors. 3

Critical Pitfall to Avoid

Overreliance on chart review can perpetuate diagnostic errors—always verify key elements directly with the patient. 5, 3 Allow patients to tell their story in their own words before integrating chart review information, or they may feel their narrative is being ignored. 3, 4

Informant Interview

Always seek an informant (care partner, family member) when possible, particularly for patients with cognitive or behavioral concerns. 1, 4 Informant reports provide added value beyond patient history alone and are essential when diminished insight accompanies the presenting condition. 1 Document the informant's relationship to patient, length of relationship, amount and type of contact, and their own demographic details. 4

Disease-Specific and Risk Factor Assessment

Systematically document:

• Cardiovascular risk factors: History of myocardial infarction, arrhythmia, heart failure, angina, peripheral artery disease, hypertension, diabetes, and lipid measurements 1, 4
• Family history: First-degree relatives with relevant conditions, including age at onset and age at death 4
• Environmental and occupational exposures: Use structured questionnaires adapted to regional geography, workplace exposures, home environment, animal contact, and travel history 1, 4
• Social determinants of health: Food insecurity, housing stability, transportation access, financial barriers, social support networks, tobacco/alcohol/substance use 5, 4

Preventive Care and Screening

Document vaccination status, cancer screening status, sexually transmitted disease screening if indicated, and results of depression/anxiety screening. 5 For elderly patients, include cognitive and functional performance assessments. 5

Organizational Best Practices

Structure the HPI chronologically, sequencing both relevant historical risks and known medical events to improve diagnostic reasoning. 5 Synthesize information from patient interview, informant reports, and prior documentation into a coherent narrative that supports clinical reasoning. 3 Cross-reference information from multiple sources to verify key historical elements. 5

Quality and Efficiency Considerations

Computer-generated HPIs using structured symptom collection algorithms have been shown to produce higher quality documentation than physician-written notes—scoring better on completeness, organization, usefulness, and comprehensibility. 6, 7 However, the artful elicitation of the HPI remains "an interactive exercise in spontaneity, unexpected responses, and nimble redirection" that requires clinical judgment. 1

Avoid making the HPI unwieldy with excessive chart review details—be selective and include only information relevant to the current presentation. 5 Document the rationale for treatment decisions to support the clinical reasoning process. 5