Template For Documenting A Patient’s History Of Present Illness

A History of Present Illness (HPI) template is an essential tool for healthcare providers to gather detailed information about a patient’s current medical condition. A well-designed template can streamline the intake process, improve patient care, and facilitate accurate diagnosis and treatment.

Key Elements of a Professional HPI Template:

Patient Information

Patient Name: Include the patient’s full name.

Date of Birth: Provide the patient’s birthdate.

Date of Visit: Specify the date of the consultation.

Medical Record Number: Enter the patient’s unique medical record identifier.

Chief Complaint (CC)

Primary Reason for Visit: Clearly state the main reason the patient is seeking medical attention.

History of Present Illness (HPI)

Onset: When did the symptoms begin?

Location: Where are the symptoms located?

Duration: How long have the symptoms lasted?

Character: Describe the nature of the symptoms (e.g., sharp, dull, throbbing).

Severity: Rate the intensity of the symptoms on a scale of 1-10.

Aggravating Factors: What makes the symptoms worse?

Relieving Factors: What makes the symptoms better?

Associated Symptoms: Are there any other symptoms present?

Past Medical History (PMH)

Allergies: List any known allergies to medications, food, or environmental substances.

Medications: Record all current medications, including dosage, frequency, and reason for use.

Surgeries: Note any previous surgeries and their dates.

Hospitalizations: List any hospitalizations, including dates and reasons.

Immunizations: Indicate the patient’s immunization status.

Significant Medical Conditions: Specify any chronic or recurrent health problems.

Family History (FH)

First-Degree Relatives: Note any significant medical conditions or early deaths among the patient’s parents, siblings, and children.

Second-Degree Relatives: Consider including information about grandparents, aunts, uncles, and cousins if relevant.

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Social History (SH)

Tobacco Use: Ask about the patient’s smoking history, including pack-years.

Alcohol Use: Inquire about the patient’s alcohol consumption habits.

Drug Use: Ask about any current or past use of illicit drugs.

Occupation: Determine the patient’s current and past occupations.

Marital Status: Record the patient’s marital status.

Living Situation: Ask about the patient’s living arrangements.

Exercise: Inquire about the patient’s exercise habits.

Diet: Ask about the patient’s typical dietary habits.

Review of Systems (ROS)

Constitutional: Ask about changes in weight, fever, chills, fatigue, or night sweats.

Head and Neck: Inquire about headaches, dizziness, vision changes, hearing loss, or neck pain.

Respiratory: Ask about cough, shortness of breath, chest pain, or wheezing.

Cardiovascular: Inquire about chest pain, palpitations, shortness of breath, or swelling.

Gastrointestinal: Ask about abdominal pain, nausea, vomiting, diarrhea, or constipation.

Genitourinary: Inquire about urinary frequency, urgency, dysuria, or changes in urinary habits.

Musculoskeletal: Ask about joint pain, stiffness, muscle weakness, or swelling.

Neurological: Inquire about changes in mental status, memory, speech, or coordination.

Skin: Ask about rashes, itching, or changes in skin color.

Endocrine: Inquire about thyroid problems, diabetes, or other endocrine disorders.

Design Considerations for a Professional HPI Template:

Clear and Concise Language: Use simple, straightforward language that is easy for patients to understand.

Logical Organization: Arrange the information in a logical sequence that facilitates data entry and retrieval.

Consistent Formatting: Use consistent fonts, spacing, and alignment throughout the template.

Professional Appearance: Choose a clean and professional design that reflects the credibility of the healthcare provider.

Electronic Format: Consider using an electronic template that can be easily filled out, saved, and shared.

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By following these guidelines, healthcare providers can create a professional and effective History of Present Illness template that improves the quality of patient care and facilitates accurate diagnosis and treatment.