Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Date of Visit:
Chief Complaint (CC):
Briefly summarize the patient’s main reason for seeking medical attention in their own words, as captured in the CC note.
HPI Elements:
LOCATION: Specify the anatomic location of the patient’s symptoms (e.g., “chest pain”, “abdominal pain”).
CHARACTER: Describe the quality of the symptoms using descriptive terms (e.g., “sharp”, “aching”, “burning”).
ONSET: Indicate when the symptoms began (e.g., “3 days ago”, “gradual onset over past week”).
DURATION: Mention how long the symptoms have been present (e.g., “constant”, “comes and goes”).
SEVERITY: Describe the intensity of the symptoms (e.g., “mild”, “moderate”, “severe”).
FREQUENCY: If applicable, note how often the symptoms occur (e.g., “daily”, “episodic”).
ALLEVIATING FACTORS: Mention anything that makes the symptoms feel better (e.g., “improved with rest”, ” relieved by medications”).
EXACERBATING FACTORS: Mention anything that makes the symptoms worse (e.g., “worsens with activity”, “triggered by certain foods”).
ASSOCIATED SYMPTOMS: List any other symptoms that may be related to the primary complaint (e.g., “fever”, “nausea”, “vomiting”).
Example:
Chief Complaint: Cough
HPI: The patient reports a cough that started 3 days ago. The cough is described as dry and hacking, and occurs in frequent bursts throughout the day. It is worse at night and disrupts sleep. The patient denies fever, chest pain, or shortness of breath. They haven’t noticed any specific triggers or alleviating factors for the cough.
Additional Considerations:
You can tailor the level of detail in the HPI based on the complexity of the case.
For simple complaints, a brief description might suffice.
More complex presentations may require a more thorough exploration of each HPI element.
Use the patient’s own words whenever possible to capture the nuances of their experience.
Document the information chronologically, starting with the onset of symptoms and progression over time.
Remember: The HPI plays a vital role in understanding the patient’s illness and formulating a diagnosis. It provides a comprehensive picture of the current health concern beyond the initial chief complaint.