The History of Present Illness (HPI) is the structured narrative section within a medical record that details the symptoms and progression of a patient’s primary health complaint. It serves as a chronological account of the current problem, beginning from its first sign or symptom up to the moment of the medical encounter. This detailed story, obtained through specific interview questions, is fundamental for guiding a healthcare provider’s assessment, supporting clinical decision-making, and ensuring clear communication among the care team. A well-documented HPI converts the patient’s experience into a clear, usable format that helps narrow down potential diagnoses.
Setting the Stage: The Chief Complaint
The HPI always begins with establishing the Chief Complaint (CC), which is the primary reason for the patient’s visit. The CC is typically a concise statement, often captured in the patient’s own words, such as “headache for three days” or “pain in my left knee.” This statement focuses the provider’s attention on the most pressing concern.
The HPI then expands upon this complaint, providing the necessary context and specificity that the CC lacks. The narrative is exclusively dedicated to elaborating on the CC, ensuring the documented story remains relevant to the problem that brought the patient in. Without a clearly defined Chief Complaint, the subsequent detailed history can become disorganized and less effective for diagnostic purposes.
The Eight Descriptive Elements
The core of the HPI is the systematic description of the patient’s symptom using eight standardized descriptive elements. These elements ensure a comprehensive characterization of the illness. Providers often use structured interviews to gather specific information on each component.
- Location: Identifies the precise anatomical site of the symptom (e.g., the left wrist or diffuse abdominal area).
- Quality: Describes the subjective nature of the symptom, using descriptors like “sharp,” “throbbing,” or “burning” to characterize the sensation.
- Severity: Measures the intensity of the complaint, often quantified using a pain scale (e.g., 7 out of 10), or by describing its impact.
- Duration: Establishes the total length of time the symptom has been present since its onset (e.g., “three days” or “on and off for several weeks”).
- Timing: Focuses on the pattern or frequency, distinguishing between continuous presence, intermittent occurrence, or specific times of day.
- Context: Details the circumstances surrounding the onset of the symptom, including what the patient was doing or environmental factors (e.g., “started after lifting a heavy box”).
- Modifying Factors: Describes anything that makes the symptom better or worse, such as improvement with medication or worsening when walking.
- Associated Signs and Symptoms: Notes other related symptoms that are present or conspicuously absent. For instance, a headache might be accompanied by nausea.
Scope and Context in Medical Documentation
The History of Present Illness is a focused narrative, distinct from other sections of the patient’s medical history which provide necessary background information. The HPI is strictly confined to the current problem, ensuring the diagnostic process remains centered on the reason for the visit.
The HPI should not be confused with the Review of Systems (ROS), which is a broader, structured inventory of body systems gathered through a series of questions. While the HPI details the characteristics of the main symptom, the ROS screens for other signs or symptoms across multiple systems, such as asking about fever, weight changes, or vision problems. The ROS helps uncover potential problems or rule out diagnoses that might not be obvious from the HPI alone.
Furthermore, the HPI is separate from the Past Medical History (PMH), which documents chronic conditions, prior surgeries, and hospitalizations, and the Social History (SHx), which covers lifestyle factors like tobacco use or occupation. While a patient’s history of diabetes or their smoking habit may influence the current illness, the HPI maintains its focus on the chronological development and characteristics of the symptom currently being evaluated. By keeping these sections distinct, the overall medical record provides a complete and organized clinical picture.