History of Present Illness in a Hurry
As a required component of any E/M service, the history of present illness (HPI) is a chronological description of the development of the patient’s present illness, from the first sign or symptom, or previous encounter, to the present. Both the 1995 and 1997 Evaluation and Management Documentation Guidelines quantify the HPI by:
- Location: Patient statements regarding the anatomical place, position, or site of the chief complaint. Examples include: “back pain,” “sore elbow,” “cut on leg,” etc.
- Quality:Patient statements regarding characteristics about the problem, such as how it looks or feels. For example: “yellow discharge,” “popping knee,” “throbbing pain,” etc.
- Severity:Patient statements regarding a degree or measurement of how bad it is. For example: “improved,” “unbearable pain,” “blood sugar 205,” etc.
- Duration: Patient statements regarding how long the complaint has been occurring, or when it first occurred. For example: “since childhood,” “first noticed a month ago,” “on and off for several weeks,” etc.
- Timing: Patient statements regarding a measurement of when, or at what frequency, he or she notices a problem. For example: “intermittent,” “constant,” “only in the evening,” etc.
- Context: Patient statements regarding what the patient was doing, environmental factors, and/or circumstances surrounding the complaint. For example: “while standing,” “during exercise,” “after a fall,” etc.
- Modifying factors: Patient’s statements regarding anything that makes the problem better or worse. For example, “improves with aspirin,” “worse when sitting,” “better when lying down,” etc.
- Associated signs and symptoms: Patient’s statements regarding associate, secondary complaints.
The 1997 Documentation Guidelines also allow credit in the history of present illness for patients who are seen for chronic conditions—for example, if the patient states, “I am here today to follow up with my COPD.” Statements of this type are not credited specifically under the 1995 Documentation Guidelines, but may be given credit by the 1997 Documentation Guidelines as chronic conditions when the status of those conditions are the reason for the visit.
There are two levels of HPI:
- A brief HPI correlates to an expanded problem-focused level of work. For both the 1995 and 1997 documentation guidelines, the history of present illness is brief if at least one of the eight elements that quantify HPI (location, quality, severity, etc.) is documented.
- The second level of HPI, an extended HPI, correlates to a comprehensive level of work. For both the 1995 and 1997 documentation guidelines, the HPI is extended if at least four of the eight elements that quantify HPI are documented. For the 1997 documentation guidelines only, patient statements regarding the status of at least three chronic conditions also may be considered an extended HPI.