The History of Present Illness (HPI) is the narrative section of a patient’s medical record that details the symptoms and events leading up to a healthcare visit. It serves as the foundational story for the patient’s chief complaint, which is the primary reason they are seeking medical attention. The HPI is a subjective account, meaning the information comes directly from the patient’s perspective. It transforms a simple complaint, such as “headache,” into a comprehensive, decision-ready clinical picture. This narrative allows clinicians to understand the progression of the illness, which is essential for diagnostic reasoning and care planning.
The Essential Components of the HPI
A complete HPI requires the collection of specific data points, often referred to as the eight elements of the history of present illness. These elements ensure a thorough characterization of the patient’s symptoms. The first element is Location, identifying the precise area of the body where the symptom is occurring, such as “left-sided chest” or “right knee”. Next is Quality, which describes the physical characteristics of the symptom, using terms like “stabbing,” “burning,” or “throbbing” for pain, or “paroxysmal” for cough.
Severity quantifies the symptom’s intensity, commonly measured using a pain scale of one to ten, or descriptive words like “mild,” “moderate,” or “severe”. Duration establishes how long the problem has been present, while Timing addresses the frequency (intermittent, constant, or specific time of day). The Context or setting describes the circumstances surrounding the symptom’s occurrence, including the activity the patient was engaged in when symptoms began.
Modifying factors detail what makes the symptom better or worse, including actions, positions, or self-administered treatments. The final element involves Associated signs and symptoms, which are any other related complaints the patient is experiencing. Clinicians often use organizational mnemonics like OLDCARTS or OPQRST to ensure all points are covered during the patient interview. While these mnemonics guide information gathering, the written HPI must be a cohesive narrative rather than a simple list of answers.
Structuring the HPI Narrative
Once the data points are collected, they must be arranged into a logical, readable narrative that tells the story of the illness. An effective HPI begins with a succinct opening sentence that frames the story, typically including the patient’s age, sex, and the chief complaint with its duration. For example, a clear opening might be, “The patient is a 54-year-old male with a history of hypertension presenting with three hours of crushing substernal chest pressure.” This immediate context anchors the reader to the central problem.
One common organizational method is the Chronological structure, best suited for acute, single-issue complaints like an infection or injury. This approach follows the development of the illness from the first sign or symptom to the present moment, placing all events in sequential order with clear timelines. Using precise time stamps, such as “three days prior to arrival,” helps establish a clear progression and track changes in symptoms over time.
For more complex or chronic conditions, a Symptom-based structure is often more effective, focusing on one major complaint at a time. This method groups all relevant details (location, quality, modifying factors, etc.) for a single symptom before transitioning to another coexisting complaint, such as chronic fatigue or persistent joint pain. Regardless of the structure chosen, the narrative should flow like a concise clinical story that is easy for any other healthcare provider to follow. The narrative concludes with a sentence summarizing the patient’s current status or the clinical concern that prompted the visit.
Practical Tips for Clarity and Conciseness
Achieving clarity in the HPI requires using professional, yet straightforward language, while avoiding unnecessary medical jargon or vague terminology. The patient’s own words should be used in quotation marks when they provide a particularly descriptive account of their experience, such as a specific quality of pain. However, the overall narrative must be written in a professional prose style, not as a list of questions and answers.
A technique for conciseness is the effective use of pertinent negatives, which are symptoms the patient denies that are relevant to ruling out potential diagnoses. For instance, in a patient with chest pain, documenting “patient denies shortness of breath or arm pain” is informative because it helps narrow diagnostic possibilities. Including these targeted negatives demonstrates that the clinician considered a broader range of conditions.
To maintain focus, only information directly related to the chief complaint and the current episode of illness should be included in the HPI. Relevant context from the patient’s past medical, family, or social history should be integrated only if directly pertinent to the current problem, such as including a history of smoking for a patient presenting with a cough. The final narrative must fully explain the reason the patient presented for care, ensuring the note is complete while avoiding repetition.