History of Present Illness: The Who, What, When, Where

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.

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