The History of Present Illness (HPI) is the narrative foundation of a patient’s medical record, serving as the professional account of why a patient is seeking care. It transforms the patient’s initial complaint into a structured, medically relevant story. This process documents the acute complaint and the circumstances surrounding its development, providing context for subsequent diagnostic and treatment decisions. A well-written HPI ensures clear communication across the care team, influencing the accuracy of diagnosis.
Defining the HPI and its Role
The HPI is a focused, chronological description of the patient’s current illness, beginning from the first symptom up to the moment of the encounter. Its specific scope is to elaborate solely on the chief complaint, which is the primary reason for the visit. This focused approach sets the HPI apart from the Past Medical History (PMH), which details prior illnesses, surgeries, and chronic conditions.
The HPI is also distinct from the Review of Systems (ROS), which is a broad inventory of symptoms across all major body systems. The HPI is narrowly concentrated on the current problem, providing the detail necessary to establish medical necessity for testing and treatment. Detailing the present illness guides the clinician’s initial thinking and helps establish a differential diagnosis.
Standard Frameworks for Data Collection
Gathering detailed information for the HPI requires a systematic approach to ensure no aspect of the symptom is overlooked. Healthcare professionals use mnemonic frameworks, such as OLDCARTS and OPQRST, to structure the patient interview and capture the eight core characteristics of any symptom.
The OLDCARTS mnemonic breaks down the symptom into eight distinct elements: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, and Severity. Onset focuses on precisely when the problem began and what the patient was doing at the time. Location identifies the exact site of the problem and whether it radiates or moves to other areas.
Duration determines how long the symptom has persisted. Characteristics seek a descriptive quality, such as whether pain is sharp, dull, or crushing. Aggravating factors and Relieving factors identify what makes the symptom worse or better, including any interventions the patient has attempted.
Timing refers to the pattern of the symptom, such as whether it is constant, intermittent, or worse at a certain time of day. Severity quantifies the symptom, often using a pain scale of one to ten, to gauge the patient’s level of distress.
The alternative OPQRST framework is often used specifically for pain assessment, covering Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Timing. Regardless of the mnemonic used, the goal is to collect sufficient detail to fully characterize the current problem. Capturing at least four descriptive elements is considered the minimum for a detailed HPI.
Constructing the Written Narrative
The collected data points must be synthesized into a concise, professional, and well-structured narrative. Documentation should begin with a brief introductory sentence including the patient’s age, gender, and any pertinent past medical history related to the chief complaint. For example, the note might start with, “A 65-year-old male with a history of coronary artery disease presents with…”.
The body of the HPI must follow a clear chronology, detailing the evolution of the symptom from its onset to the present encounter. This section should not be a fragmented list of answers to the mnemonic questions, but a flowing prose that tells the patient’s story. The narrative should integrate the details of location, quality, and severity in a way that logically builds the case for the suspected diagnosis.
A thorough HPI also incorporates “pertinent positives” and “pertinent negatives.” Pertinent positives are associated symptoms the patient reports that support a specific diagnosis, such as shortness of breath accompanying chest pain. Pertinent negatives are the absence of symptoms that might point toward an alternative diagnosis, for instance, denying fever or cough in the context of chest pain to make pneumonia less likely.
It is important to maintain an objective tone throughout the written HPI, avoiding judgmental language or speculation. The focus must be on accurately documenting the patient’s account and the relevant findings.