History of Present Illness: The Who, What, When, Where
- By Katreece Tate
- In Coding
- June 19, 2017
- Comments Off on History of Present Illness: The Who, What, When, Where
To determine what to include in the History of Present Illness (HPI), keep these questions in mind.
Location – Where is the pain? Where is the problem?
Ex. back pain, nasal congestion
Quality – Please describe your symptoms (Action words)
Ex. sharp or shooting pain, dry cough
Severity – What is the patient’s level of discomfort or pain?
Ex. extremely nauseated, moderate pain
Duration – How long has the patient had this problem?
Ex. onset two weeks ago
Timing – How long does it last? When does this problem happen? What time of day does this problem occur?
Ex. worse in the mornings, occurs constantly
Context – How or what happened? What is going on?
Ex. Dizzy upon standing, worse after exercise
Modifying factors – What has the patient taken or done for relief?
Ex. No relief from OTC meds, improves with rest
Associated signs and symptoms – This can be positive or negative.
Ex. a chief complaint of nausea may be accompanied by associated symptoms of vomiting and diarrhea, no fever
Remember: Listing three of the patient’s chronic problems, along with the status, could be considered a comprehensive HPI.
Ex. Diabetes Mellitus, stable on current insulin
CHF, worse since last visit due to weather
Osteoarthritis, improved with increase in RX
The question “Who” can be used to add to the complexity in the Medical Decision Making (MDM) in the amount and complexity of data to be reviewed. Simply put, who is giving the history? This must be documented in the note.
Ex. History was given by mom/dad
History was given by patient’s daughter/son
History was given by patient’s spouse
Remember: To reach a comprehensive HPI, you need at least four of the eight elements, listed above.
- History of Present Illness: The Who, What, When, Where - June 19, 2017
Is that 4 elements per issue? Pt comes in for UTI and pain in hip. HPI “It hurts when I pee. Pain in right hip (L) caused by falling from bike,(C) taken Aleve with no relief (M).” That is 4 elements. However only 3 for hip. Do I have an Extended HPI?