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 features, risk factors, and functional impact to guide evidence-based management decisions.

Essential Diagnostic Elements

Primary Symptoms (Must Document)

• Dyspnea characteristics: Onset, progression (chronic and progressive is most characteristic), severity, timing (at rest vs. exertional), and any variation throughout the day 1
• Cough pattern: Duration (chronic cough often first symptom), frequency, timing, productivity, and whether patient attributes it to smoking/environmental exposures 1
• Sputum production: Volume, color (purulent vs. non-purulent), consistency, and duration (classic chronic bronchitis definition: regular production for ≥3 months in 2 consecutive years) 1, 2
• Wheezing and chest tightness: Presence, timing, and daily variation 1

Exacerbation Assessment (Critical for Acute Presentations)

Document presence of ≥2 of the following major criteria (triggers antibiotic consideration per BTS guidelines):

• Increased breathlessness 1
• Increased sputum volume 1
• Development of purulent sputum 1

Minor symptoms to document:

• Sore throat, colds (nasal discharge/congestion), fever without other cause, increased cough or wheeze 3
• Duration of symptoms (≥2 consecutive days for exacerbation definition) 3

Risk Factor Documentation

Smoking History (Mandatory)

• Pack-years calculation: Total years smoked × packs per day 1, 4
• Current smoking status: Active, former (quit date), or never 1
• Clinical significance thresholds: >40 pack-years strongly suggests COPD; <10 pack-years warrants specialist referral to encourage early intervention 1, 4

Occupational and Environmental Exposures

• Specific workplace exposures (dusts, chemicals, fumes) 1
• Biomass fuel exposure, indoor/outdoor air pollution 1

Past Medical History Elements

Respiratory History

• Childhood respiratory infections 1
• Asthma, allergy, sinusitis, or nasal polyps (may coexist with COPD) 1
• Age of symptom onset (COPD <40 years requires α1-antitrypsin deficiency screening) 1
• Pattern of symptom development: More frequent or prolonged "winter colds," social restriction 1

Exacerbation History

• Number of exacerbations in past year (≥1 moderate/severe exacerbation indicates high-risk phenotype) 3
• Previous hospitalizations for respiratory disorder 1
• Emergency department visits 1
• ICU admissions or intubations 1

Family History

• COPD or other chronic respiratory diseases in family members 1
• Early-onset emphysema (suggests α1-antitrypsin deficiency) 1

Comorbidity Assessment

Document presence of:

• Heart disease (cor pulmonale assessment critical) 1
• Osteoporosis 1
• Musculoskeletal disorders 1
• Malignancies 1
• Depression and anxiety (common and undertreated) 1

Functional Impact and Quality of Life

Activity Limitation

• Specific activities affected: Walking distance, stair climbing, self-care activities 1
• Exercise capacity changes 1
• Missed work days and economic impact 1

Severe Disease Features (Document if Present)

• Fatigue 1
• Weight loss 1
• Anorexia 1

Current Treatment and Response

Medication Adherence

• Current bronchodilators: Type, dose, frequency, and perceived effectiveness 1
• Inhaler technique assessment: Proper use vs. improper technique 1
• Corticosteroid use: Oral or inhaled, duration, response 1
• Oxygen therapy: Type (LTOT, ambulatory, short-burst), flow rate, hours per day 1

Previous Interventions

• Pulmonary rehabilitation participation and response 1
• Smoking cessation attempts and methods used 1

Social Support and Coping

• Patient's ability to cope with disease 1
• Social and family support available 1
• Living situation and caregiver availability 1

Objective Data to Reference

Spirometry Results (Essential)

• Most recent FEV1 value and percent predicted 1
• FEV1/FVC ratio (post-bronchodilator <0.70 confirms diagnosis) 1
• Reversibility percentage (helps differentiate from asthma) 1, 2
• Rate of FEV1 decline (rapid decline warrants specialist referral) 1

Additional Testing

• Arterial blood gas results if available (PaO2 <7.3 kPa indicates need for LTOT assessment) 1
• Chest imaging findings 1
• DLCO if measured (reduced in emphysema, preserved in pure bronchitis) 2

Red Flags Requiring Specialist Referral

Document if any present:

• Suspected severe COPD 1
• Onset of cor pulmonale 1
• Symptoms disproportionate to lung function deficit 1, 2
• Uncertain diagnosis 1
• Frequent infections (exclude bronchiectasis) 1
• Bullous lung disease 1
• Rapid FEV1 decline 1