What should be included in a Cerner-friendly History of Present Illness (HPI) template for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

COPD History of Present Illness (HPI) Template for Cerner

A comprehensive COPD HPI template should systematically capture key diagnostic criteria, symptom characteristics, exacerbation history, functional impact, and risk factors in a structured format that facilitates clinical decision-making and documentation.

Essential Diagnostic Elements

Respiratory Symptoms

• Dyspnea: Document onset, progression (chronic and progressive is characteristic), severity using Modified Medical Research Council (mMRC) scale (0-4), and triggers 1
• Chronic cough: Note duration (often the first symptom), frequency, timing, and whether patient attributes it to smoking 1
• Sputum production: Quantify volume, color (purulent vs. non-purulent), consistency, and duration (classic chronic bronchitis = 3+ months in 2 consecutive years) 1
• Wheezing and chest tightness: Document variability throughout the day and between days 1

Advanced Disease Features

• Systemic symptoms: Weight loss, anorexia, fatigue (common in severe COPD) 1
• Functional limitations: Specific activities affected, missed work, social restrictions 1

Risk Factor Assessment

Exposure History

• Tobacco use: Pack-years (minimum 10 pack-years for diagnosis consideration), current vs. former status, quit date if applicable 1
• Occupational exposures: Specific dusts, chemicals, fumes, duration of exposure 1
• Environmental exposures: Indoor/outdoor air pollution, biomass fuel exposure 1

Medical History

• Prior respiratory conditions: Asthma (risk factor for COPD development), childhood respiratory infections, allergies, sinusitis, nasal polyps 1
• Family history: COPD or other chronic respiratory diseases in first-degree relatives 1
• Alpha-1 antitrypsin deficiency: Especially if COPD onset <40 years or minimal smoking history 1

Exacerbation History

Current Exacerbation (if applicable)

• Cardinal symptoms: Increased dyspnea, increased sputum volume, development of purulent sputum (≥2 of these indicate need for antibiotics) 1, 2
• Timing: Onset, duration, progression 3
• Triggers: Recent respiratory infection, environmental exposure, medication non-adherence 3

Historical Exacerbations

• Frequency: Number in preceding year (≥2 exacerbations or ≥1 hospitalization = high risk) 1, 4, 2
• Severity: Outpatient management vs. hospitalizations vs. ICU admissions 1
• Treatment response: Previous therapies used and effectiveness 3

Spirometry and Disease Severity

Objective Measurements

• Post-bronchodilator spirometry: FEV1/FVC ratio (<0.70 confirms airflow limitation), FEV1 % predicted for severity classification 1, 4
• GOLD classification: Mild (FEV1 ≥80%), Moderate (50-80%), Severe (30-50%), Very Severe (<30%) 1, 2
• Bronchodilator reversibility: Document if tested (≥10% increase in FEV1 post-bronchodilator) 5

Functional Assessment

• mMRC dyspnea scale: Grade 0-4 (≥2 indicates high symptom burden) 1, 4
• Exercise capacity: 6-minute walk distance if available 4
• BMI: Document if <21 kg/m² (associated with increased mortality) 4

Comorbidity Documentation

Cardiovascular

• Cardiac disease: Ischemic heart disease, heart failure, arrhythmias (COPD and cardiovascular disease share pathobiological pathways) 1, 2, 6
• Hypertension: Current control status 6

Other Relevant Comorbidities

• Osteoporosis: Especially in patients on chronic corticosteroids 1
• Depression/anxiety: Impact on quality of life and disease management 1
• Musculoskeletal disorders: Affecting mobility and rehabilitation 1
• Malignancies: Particularly lung cancer screening status 2, 6

Current Management and Response

Medications

• Bronchodilators: LABA, LAMA, SABA - specific agents, doses, frequency, adherence 2
• Inhaled corticosteroids: If applicable, dose and duration 2
• Systemic corticosteroids: Current or recent use 2
• Antibiotics: Recent courses, indications 2
• Oxygen therapy: If prescribed, flow rate, hours per day, compliance 2, 7

Inhaler Technique

• Device type: MDI, DPI, nebulizer 2
• Technique assessment: Document if verified (76% of COPD patients make significant errors) 2

Non-Pharmacologic Interventions

• Smoking cessation: Current status, previous attempts, pharmacotherapy used 1, 2
• Pulmonary rehabilitation: Participation status 2, 7
• Vaccinations: Influenza (annual), pneumococcal (PCV13/PPSV23) status 2

Quality of Life Impact

Functional Status

• Activities of daily living: Specific limitations (dressing, bathing, walking) 1
• Social support: Family/caregiver availability 1
• Economic impact: Work status, financial burden of disease 1
• Psychological impact: Depression, anxiety, feelings about disease 1

Physical Examination Findings

Respiratory Signs

• Respiratory rate: Document baseline 1
• Use of accessory muscles: Indicates increased work of breathing 1
• Breath sounds: Decreased, wheezing, prolonged expiration 1
• Hyperinflation signs: Barrel chest, decreased diaphragmatic excursion (typically not present until significant impairment) 1

Systemic Signs

• Weight and BMI: Trend over time 1, 4
• Cyanosis: Central vs. peripheral 1
• Edema: Suggesting cor pulmonale 1

Clinical Pitfalls to Document

• Rapid FEV1 decline: Warrants investigation for alpha-1 antitrypsin deficiency 1
• Symptoms disproportionate to spirometry: Consider alternative diagnoses or comorbidities 1
• Frequent infections: Exclude bronchiectasis 1
• Young age (<40 years) with COPD: Screen for alpha-1 antitrypsin deficiency and family members 1