Understanding the History of Present Illness
The History of Present Illness (HPI) is a chronological account of the development of a patient's chief complaint. Unlike a broad review of systems, the HPI focuses specifically on the current problem, providing clinicians with the detailed, nuanced story they need to formulate a differential diagnosis and treatment plan. For a complete medical record, especially in complex cases, an extended HPI should include at least four of the eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. You can find more details about these key elements on the {Link: Yale Assessment Module Training website https://assessment-module.yale.edu/compliance-medical-billing-training/em-key-elements-defined}.
What is an example of HPI?: A case study in chest pain
Here is a comprehensive HPI example for a patient presenting with chest pain:
Chief Complaint: Chest pain and shortness of breath.
HPI: Mr. Smith, a 45-year-old male with a history of hypertension and hyperlipidemia, presents with chest pain described as 'tight, crushing' (Quality) and located centrally (Location). The pain, rated 8/10 (Severity), started suddenly two hours ago while climbing stairs (Onset, Timing, Context). It radiates to his left arm and jaw (Associated Signs and Symptoms) and worsens with exertion (Modifying Factors). He reports associated sweating and nausea and denies previous similar episodes. Social history includes former smoking and a high-stress job.
How to structure a narrative HPI
An HPI should be written narratively, starting with a concise opening sentence that includes the patient's demographics, relevant past medical history, and chief complaint. The narrative should then describe the symptoms chronologically, integrating details from the eight HPI elements.
Chronological Narrative Example:
A 68-year-old woman with a history of type 2 diabetes presents with a cough and fever. She states the illness began three days ago with a dry cough and mild fatigue. Yesterday, the cough worsened, becoming productive of thick, yellow phlegm. She developed a fever to 101.5°F and experienced shaking chills. She has been taking over-the-counter cough syrup without relief. She denies any chest pain, shortness of breath, or headache.
Differentiating HPI types
Based on medical coding guidelines, HPI can be categorized into brief and extended versions, determined by the number of descriptive elements documented.
| Feature | Brief HPI | Extended HPI |
|---|---|---|
| Number of Elements | Documents 1 to 3 elements related to the chief complaint. | Documents 4 or more elements, or the status of 3 chronic conditions. |
| Example | "Patient reports constant, mild-intensity headaches for the past day." (Contains duration, timing, severity, quality). | "Patient reports persistent, throbbing pain in the left temple, rated 7/10, starting this morning after a stressful work meeting. The pain worsens with bright light and is not relieved by aspirin. He denies any visual changes or nausea." |
| Level of Detail | Provides a basic overview of the patient's current problem. | Provides a comprehensive, detailed story of the patient's illness, often required for more complex cases. |
| When to Use | Appropriate for a focused, follow-up visit or a simple, uncomplicated issue. | Necessary for initial comprehensive visits, complex diagnoses, or emergency department encounters. |
The importance of a precise HPI
The HPI is fundamental for effective clinical care.
- Diagnostic Tool: A detailed HPI helps clinicians narrow down the list of possible diagnoses.
- Communication and Continuity of Care: An accurate HPI ensures consistent information for all healthcare providers.
- Billing and Legal Requirements: The HPI's detail level impacts medical coding and billing, and serves as a crucial legal document.
Conclusion: The patient's story is paramount
In summary, the History of Present Illness is the cornerstone of the clinical encounter. While a simple HPI might suffice for straightforward issues, understanding what is an example of HPI? demonstrates its power in providing comprehensive, narrative context. By diligently documenting the relevant details, clinicians can construct a narrative that not only aids in diagnosis and treatment but also ensures seamless communication among the care team. Ultimately, the HPI captures the patient's unique story, allowing healthcare providers to treat the individual, not just the disease. To learn more about medical documentation standards, consult resources from authoritative sources like the {Link: Centers for Medicare & Medicaid Services (CMS) https://assessment-module.yale.edu/compliance-medical-billing-training/em-key-elements-defined}.
