The History of Present Illness (HPI) is the detailed, chronological narrative describing a patient’s chief complaint from the moment it began to the present encounter. It functions as the foundation of the medical record. The HPI is obtained through focused questioning and guides a healthcare provider toward an accurate diagnosis and appropriate treatment plan. This structured documentation ensures that every clinician reviewing the record understands the progression and nature of the current health problem.
Describing the Symptom: Core Elements of the HPI
The HPI begins by characterizing the main symptom using a set of specific, descriptive elements. One of the first details recorded is the Location, which precisely identifies where the symptom is felt, such as “right lower quadrant of the abdomen” or “bilateral temples”. This pinpointing is sometimes extended to include any Radiation, describing if the symptom, like pain, spreads to an adjacent area, such as the jaw or the arm.
Next, the Quality or character of the symptom provides a clear verbal picture of the sensation, such as a “sharp, stabbing” pain, a “dull, aching” throb, or a “burning” sensation. The Severity quantifies the intensity of the complaint, most often using a numerical rating scale from one to ten, where ten represents the worst possible experience. This standardized measurement allows clinicians to track the symptom’s intensity over time and assess the effectiveness of interventions.
The Onset and Timing elements establish the symptom’s life history, documenting when the problem first started and its pattern since. Onset can be described as sudden, like a lightning strike, or gradual, developing over days or weeks. Timing details whether the symptom is constant, intermittent, or occurs only at specific times of the day, such as being “worse in the mornings.”
Contextualizing the Complaint: Modifying and Associated Factors
The HPI narrative includes details that provide external context to the chief complaint. Modifying factors are a primary focus, documenting anything that the patient has found to make the symptom better or worse. This includes Aggravating factors, such as pain worsening with movement or eating, and Alleviating factors, like relief gained from rest, specific positions, or over-the-counter medications attempted at home.
Documenting what the patient has done to treat the problem so far gives the provider insight into the symptom’s behavior. This information is crucial for narrowing potential diagnoses because it demonstrates the complaint’s response to external influences. For example, chest pain relieved by antacids points the provider in a different direction than pain unchanged by medication.
The HPI also records Associated Signs and Symptoms, which are other seemingly related complaints occurring concurrently with the chief complaint. If the primary complaint is abdominal pain, the provider will ask about concurrent nausea, vomiting, or fever. These associated details are often the deciding factors between several possible diagnoses. Finally, the narrative includes a history of Prior Episodes, noting whether the patient has experienced this exact problem before and the details of the previous occurrence.
HPI vs. Other Medical History Components
The HPI must be differentiated from other major sections of a patient’s medical history. The Review of Systems (ROS) is an inventory of body systems that aims to uncover symptoms the patient may not have considered related to their main complaint. While the HPI is limited to the current problem, the ROS is a comprehensive checklist, asking about all major organ systems from constitutional symptoms like fever to neurological issues.
Another distinct component is the Past Medical History (PMH), which is a record of the patient’s health before the current illness. The PMH includes all prior diagnoses, past surgeries, known allergies, and current medications. Unlike the HPI, which details the present illness chronologically, the PMH gathers broader, established data necessary for overall patient care and risk assessment. The HPI is strictly about the development and characteristics of the current problem.