What information is included in a History of Present Illness (HPI)?

What's Included in a History of Present Illness (HPI)

The HPI must include a comprehensive narrative of the patient's principal symptoms, their time course, impact on daily function, and a structured survey of all relevant symptom domains, obtained from both the patient and an informant when possible. 1, 2

Core Components That Must Be Documented

Patient Narrative and Symptom Characterization

• Begin with the patient's own description of their main concern using open-ended questions like "What is the main reason you are here and what would you like to accomplish from this visit?" 2
• Document the nature and characteristics of all presenting symptoms in detail 1, 2
• Include the sequential order of symptom onset, frequency, tempo, and pattern of change over time 1
• Record any triggers, contextual features, or plausible relationships between events and symptoms 1

Functional Impact Assessment

• Document changes in activities of daily living (ADLs) and instrumental ADLs 1
• Assess impact on interpersonal relationships, personal safety, public health and safety 1
• Note the patient's living situation, self-care abilities, and need for care partner support 1, 3

Systematic Domain Survey

• Cognitive symptoms: episodic memory, executive function, language, visuospatial abilities 2, 4
• Mood and neuropsychiatric symptoms: depression, anxiety, behavioral changes 1, 4
• Sensory and motor function changes 1
• Safety assessment: specific details about suicidal or homicidal ideation when clinically indicated 2, 3

Medication and Treatment History

• Current medication regimen including prescription drugs, over-the-counter medications, supplements, and herbal remedies 3, 4
• Medication adherence, side effects, and response to treatment 3, 4
• Previous treatments attempted and their outcomes 4

Medical and Social Context

• Changes in medical and family history since last encounter, focusing on elements relevant to current presentation 4
• Pertinent medical history including cardiovascular disease, cerebrovascular disease, or stroke 4
• Family history of relevant conditions in first-degree relatives 4
• Social determinants of health: food security, housing stability, transportation access, financial security, community safety 4
• Tobacco, alcohol, and substance use patterns 4
• Physical activity and sleep behaviors 4

Informant Information

• Integrate information from both patient interview and informant/care partner, as informant reports provide added value beyond patient self-report alone, particularly when insight is impaired 2
• Clearly document the source of each piece of information (patient report vs. informant vs. chart review) 4

Organizational Structure

Chronological Framework

• Organize information chronologically, sequencing both relevant historical risks and known medical events to establish a clear timeline and progression 4, 5
• This chronological approach generates pre-event probabilities of the most likely disease causing the patient's chief concern 5

Integration of Multiple Sources

• Begin with the patient's narrative, then integrate relevant chart review information 4
• Use chart review to fill gaps in patient recollection, but clearly distinguish between information obtained directly from the patient versus from documentation 2, 4
• Cross-reference information from multiple sources to verify key historical elements and avoid perpetuating previous diagnostic errors 4

Pertinent Negatives

• Document important symptoms that are absent (pertinent negatives), as failing to document these leads to incomplete assessment 4

Critical Pitfalls to Avoid

• Failing to use a structured approach leads to missed symptoms because patients may not possess the knowledge or vocabulary to represent changes, may under-report or misclassify symptoms, and busy clinicians may not inquire about all relevant domains 1, 2
• Neglecting to interview an informant results in missing critical collateral information, particularly in conditions affecting insight 2
• Overreliance on chart review may perpetuate diagnostic errors; always verify key elements directly with the patient 4
• Not allowing patients to tell their story in their own words before integrating chart review information can make them feel their narrative is being ignored 4
• Including excessive chart review details makes the HPI unwieldy; be selective and include only information relevant to the current presentation 4

Why This Matters for Patient Outcomes

The HPI is the cornerstone of medical diagnosis and drives all subsequent diagnostic reasoning, treatment decisions, and directly impacts patient outcomes 1, 2. In some conditions, exposure history obtained through HPI was the strongest predictor of disease with an odds ratio of 38.8, achieving 86% sensitivity and 86% specificity when combined with other variables 2. A comprehensive HPI establishes pretest probability of disease, which is essential for interpreting all subsequent diagnostic tests and minimizing the risk of misdiagnosis 2.