The History of Present Illness (HPI) template is a crucial component of medical documentation. It provides a structured framework for clinicians to gather essential information about a patient’s current health condition. A well-designed HPI template can enhance patient care, improve communication among healthcare providers, and contribute to accurate diagnosis and treatment planning.
Key Elements of a Professional HPI Template:
Patient Demographics
HPI template & Example Free PDF Download
Patient Name: Include the patient’s full name.
Date of Birth: Provide the patient’s date of birth.
Medical Record Number: Reference the patient’s unique medical record identifier.
Date and Time of Visit
Date: Specify the date of the patient’s visit.
Time: Indicate the approximate time of the visit.
Presenting Complaint
Chief Complaint: Clearly state the primary reason for the patient’s visit in the patient’s own words.
Duration: Note the duration of the presenting complaint.
Severity: Assess the intensity or severity of the complaint (e.g., mild, moderate, severe).
Onset: Determine when the complaint began.
Location: Identify the specific location of the complaint (e.g., chest, abdomen, limb).
Quality: Describe the nature or character of the complaint (e.g., sharp, dull, throbbing).
Aggravating Factors: List any factors that worsen the complaint.
Relieving Factors: Identify any factors that alleviate the complaint.
Associated Symptoms: Note any other symptoms that accompany the presenting complaint.
Review of Systems
Constitutional: Ask about changes in weight, fever, chills, night sweats, fatigue, or weakness.
Head and Neck: Inquire about headaches, dizziness, lightheadedness, neck pain, or visual disturbances.
Eyes: Ask about vision changes, eye pain, redness, or discharge.
Ears: Inquire about hearing loss, ear pain, tinnitus, or vertigo.
Nose and Mouth: Ask about nasal congestion, runny nose, sneezing, sore throat, or mouth ulcers.
Respiratory: Inquire about cough, shortness of breath, chest pain, or wheezing.
Cardiovascular: Ask about chest pain, palpitations, shortness of breath, or swelling.
Gastrointestinal: Inquire about abdominal pain, nausea, vomiting, diarrhea, constipation, or changes in appetite.
Genitourinary: Ask about urinary frequency, urgency, dysuria, hematuria, or changes in sexual function.
Musculoskeletal: Inquire about joint pain, stiffness, swelling, or muscle weakness.
Neurological: Ask about changes in mental status, memory, mood, or coordination.
Skin: Inquire about rashes, itching, or changes in skin color.
Chronic Conditions: List any ongoing health conditions (e.g., diabetes, hypertension, asthma).
Surgeries: Note any previous surgical procedures.
Hospitalizations: Record any past hospitalizations.
Allergies: Identify any known allergies (e.g., medications, food).
Immunizations: Document the patient’s immunization history.
Family History
Significant Medical Conditions: Ask about any significant medical conditions in the patient’s family (e.g., heart disease, cancer, diabetes).
Social History
Tobacco Use: Inquire about the patient’s smoking history.
Alcohol Use: Ask about the patient’s alcohol consumption.
Drug Use: Inquire about the patient’s use of illicit drugs or prescription medications.
Occupation: Note the patient’s current occupation.
Marital Status: Record the patient’s marital status.
Living Situation: Ask about the patient’s living arrangement.
Design Considerations for a Professional HPI Template:
Clarity and Conciseness: Use clear and concise language to avoid confusion.
Organization: Structure the template in a logical and easy-to-follow manner.
Consistency: Maintain consistent formatting and terminology throughout the template.
Accessibility: Ensure the template is accessible to users with disabilities.
Customization: Allow for customization to meet the specific needs of different healthcare settings.
WordPress Implementation:
Create a New Page: In your WordPress dashboard, create a new page titled “History of Present Illness Template.”
Add Text Blocks: Use text blocks to add the various sections of the HPI template.
Format Text: Use heading tags (
,
) to organize the content and improve readability.
Customize Appearance: Apply your organization’s branding and styles to create a professional look.
Save and Publish: Save the page and make it accessible to authorized users.
By following these guidelines and utilizing WordPress, you can create a professional and effective History of Present Illness template that enhances patient care and improves communication within your healthcare organization.
