Wiki Tools for documenting HPI


True Blue
Ellington, CT
Best answers
Hi everyone,
My docs are looking for some type of tool they can use to help them remember what they need to document for HPI. We have medicare's E/M Documentation Auditors' Instructions, but this doesn't really help them. I figured rather than reinventing the wheel I'd see if anyone has something they use. Thanks.

Doreen, CPC
Thanks, at least I have someplace to start. I don't know why they have such a problem with the HPI, but this seems to be their weakest area of documentation.


History of Present Illness has 8 elements, as follows:

Location - "where" - site, diffuse or localized
Quality - "what kind" - sharp, dull, constant, intermittent, improved, worse
Severity - "how bad is it" - pain scale 1-10, mild or severe
Duration - "how long" - length of time it has been present
Timing - "Is there a pattern" - relation ot something else, continuous or repetitive
Context - "what brings it on" - does it occur with a specific activity?
Modifying factors - "what makes it better or worse" - prior treatments or medications tried, worse w/ exercise, better with heat
Assoc Signs & Symptoms - "what comes with it" - symptoms that accompany the main symptom.

F Tessa Bartels, CPC, CPC-E/M
Thansk, Wendy, I replied to your message. As for the 8 elements, I have explained in every way I can think of what needs to be document. The doc I work for seem to do better with visual aids.

Doreen, CPC
Examples help

Maybe an example will help:

Patient fell off swing yesterday, and noted immediate sharp pain in left wrist. This morning wrist is noticeably swollen and bruised.
Here you have 4 elements of HPI -
Duration - yesterday
Quality - sharp
Location - left wrist
Assoc sign - swollen, bruised

OR ...

Patient with intermittent chest pain for past two days, described as "mild, more like tightness," worse with exercise such as going up stairs
This gives up 5 HPI elements (you only need 4 for highest level)
Timing - intermittent
Location - chest
Duration - two days
Quality - mild
Context - worse w/ exercise

Another thing you could do is take some of the actual HPIs your doc has documented and show how you get only 1 HPI element (for example).

Good luck!

F Tessa Bartels, CPC, CPC-E/M