History of Present Illness Note Template and Examples

Updated: December 27, 2024

The History of Present Illness (HPI) description is a key part of gathering and documenting patient information, providing a clear picture of the patient's current condition.

This article explains the importance of using an HPI template, the benefits of the OLD CARTS mnemonic, and how tools like TextExpander can streamline documentation. Examples are also provided to illustrate how to use these tools in practice effectively.

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Key Elements of an HPI Form

To ensure all key elements are noted, utilize the OLD CARTS mnemonic for structuring patient interviews. It ensures that all critical aspects of the patient’s condition are covered systematically:

  • Onset: When did the symptoms start?
  • Location: Where are the symptoms located?
  • Duration: How long have the symptoms been present?
  • Character: What is the nature of the symptoms (e.g., sharp, dull, throbbing)?
  • Aggravating factors: What makes the symptoms worse?
  • Relieving factors: What alleviates the symptoms?
  • Timing: Are the symptoms constant or intermittent?
  • Severity: How severe are the symptoms on a scale of 1 to 10?

This mnemonic helps create a concise yet comprehensive overview of the patient’s current illness, ensuring no critical detail is overlooked.

Importance of an HPI Template

An HPI template is crucial in healthcare as it ensures a systematic and thorough approach to documenting patient information. Without this history, important aspects of the patient’s health journey may be lost or inferred incorrectly by other providers, resulting in inferior care for the patient.

Benefits of Having an HPI Template

An HPI template is essential for several reasons:

  • Consistency: Ensures uniformity in documenting patient information across different healthcare providers.
  • Efficiency: Saves time by providing a structured format, reducing the need for redundant questioning.
  • Accuracy: Minimizes the risk of omitting critical information, thereby improving diagnostic accuracy.
  • Training: Serves as an educational tool for new healthcare professionals, providing them with a clear guide for patient interviews.
  • Communication: Enhances clarity and continuity of care by standardizing the documentation process, making it easier for different practitioners to understand and follow a patient’s medical history.

By adopting a standardized HPI template, medical teams can improve their diagnostic accuracy and overall patient outcomes.

How TextExpander Can Help

TextExpander can assist healthcare professionals by providing customizable templates for History of Present Illness (HPI) documentation, saving time and ensuring consistency in patient records. Using TextExpander, healthcare providers can focus more on patient care rather than administrative tasks. Benefits include:

  • Efficiency: Quick insertion of commonly used text, allowing for faster documentation.
  • Consistency: Standardized templates ensure uniform HPI documentation across all patient records.
  • Accuracy: Reduces errors by using pre-approved text snippets, enhancing the quality of patient information.

History of Present Illness Template

Here’s a basic template for documenting the History of Present Illness:

Patient Name: [Full Name]
Age: [Patient’s Age]
Date of Visit: [MM/DD/YYYY]

Chief Complaint (CC): [Patient’s primary concern]

History of Present Illness (HPI):
– Onset: [When did the symptoms start?]
– Location: [Where are the symptoms located?]
– Duration: [How long have the symptoms been present?]
– Character: [What is the nature of the symptoms?]
– Aggravating factors: [What makes the symptoms worse?]
– Relieving factors: [What alleviates the symptoms?]
– Timing: [Are the symptoms constant or intermittent?]
– Severity: [How severe are the symptoms on a scale of 1 to 10?]

History of Present Illness Examples

HPI Example 1

Patient Name: John Doe
Age: 45
Date of Visit: 07/04/2024

Chief Complaint (CC): Severe headache

History of Present Illness (HPI):

Onset: Began three days ago
Location: Bilateral temples
Duration: Persistent
Character: Throbbing pain
Aggravating factors: Bright lights and loud noises
Relieving factors: Rest in a dark, quiet room
Timing: Constant, worsens in the evening
Severity: 7/10

HPI Example 2

Patient Name: Jane Smith
Age: 30
Date of Visit: 07/04/2024

Chief Complaint (CC): Abdominal pain

History of Present Illness (HPI):

Onset: Started one week ago
Location: Lower right quadrant
Duration: Intermittent
Character: Sharp, stabbing pain
Aggravating factors: Eating fatty foods
Relieving factors: Lying down
Timing: Occurs after meals
Severity: 6/10

HPI Example 3

Patient Name: Robert Johnson
Age: 52
Date of Visit: 07/04/2024

Chief Complaint (CC): Cough

History of Present Illness (HPI):

Onset: Two weeks ago
Location: Chest and throat
Duration: Persistent, worse at night
Character: Dry, hacking cough
Aggravating factors: Cold air, talking
Relieving factors: Warm drinks
Timing: Intermittent, worse at night
Severity: 5/10

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Patient Name: [Full Name] <br>Age: [Patient's Age] <br>Date of Visit: [MM/DD/YYYY] <br> <br>Chief Complaint (CC): [Patient's primary concern] <br> <br>History of Present Illness (HPI): <br>- Onset: [When did the symptoms start?] <br>- Location: [Where are the symptoms located?] <br>- Duration: [How long have the symptoms been present?] <br>- Character: [What is the nature of the symptoms?] <br>- Aggravating factors: [What makes the symptoms worse?] <br>- Relieving factors: [What alleviates the symptoms?] <br>- Timing: [Are the symptoms constant or intermittent?] <br>- Severity: [How severe are the symptoms on a scale of 1 to 10?]

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With TextExpander, you can store and quickly expand snippets anywhere you type. That means you'll never have to misspell, memorize, or type the same things over and over, ever again.

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