HPI Template

What is history of present illness (HPI)?

The History of present illness (HPI) is a detailed, chronological description of the development of the patient's illness from the first sign or symptom to reach the present. It forms a component of the medical history, capturing critical details about the patient's complaints.

Understanding the HPI is crucial as it helps healthcare providers diagnose and manage patients more effectively. It provides context to the patient’s current health status and can reveal the severity and impact of the condition on the patient's life.

How to obtain a patient's history of present illness?

To effectively gather a patient's history of present illness (HPI), healthcare providers can use the OLD CARTS mnemonic as a guide for short, structured interviewing. This approach ensures a comprehensive assessment of the patient's condition by covering all crucial aspects of their symptoms:

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

By methodically addressing each of these categories, healthcare providers can capture a detailed and actionable history that aids in effectively diagnosing and managing the patient's condition.

How does our HPI template work?

To effectively utilize our HPI template:

1. Download our template: Our structured printable HPI template is designed to streamline the data collection process during patient assessments.
2. Systematic data entry: The template guides clinicians through essential questions and fields tailored to capture detailed and relevant information about the patient's illness.
3. Comprehensive coverage: Using our template, clinicians can ensure that no critical information is overlooked, from the onset and severity of symptoms to their impact on daily activities.
4. Documentation efficiency: This structured approach not only aids in the accurate collection of the HPI but also enhances the efficiency of documentation, allowing for a smoother and faster patient interview process.

By following these steps, healthcare providers can leverage our HPI template to ensure thorough and accurate patient assessments occur, aiding in effective diagnosis and management.

HPI template example (sample)

Our free HPI template PDF example is invaluable for healthcare professionals seeking to enhance patient assessments. It demonstrates how to methodically capture the History of Present Illness by guiding users through each component of the HPI process.

The example features sections that correlate with the OLD CARTS mnemonic—Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity—ensuring comprehensive coverage of all necessary details.

Ideal for training and practical application, this template simplifies the documentation process, making it easier for clinicians to gather critical information efficiently and show results accurately. This approach streamlines the patient intake process and aids in forming a precise diagnosis.

Download this free history of present illness example here 

Benefits of having an HPI template

The benefits of utilizing our free HPI (History of Present Illness) template are extensive, particularly in streamlining the diagnostic process in various medical settings such as emergency departments and routine clinical practices. Here are some additional benefits:

Standardized data collection

An HPI template standardizes the collection of critical patient information for accurate and comprehensive medical records. By ensuring that all relevant details, such as the onset, location, and severity of symptoms, are consistently recorded, the template minimizes the risk of omitting crucial information.

Enhanced communication

Using a standardized HPI template improves communication among healthcare providers. When everyone uses the same format, it is easier to understand and follow the patient's history and symptoms. This is particularly valuable in emergency medical services, where time and clarity are crucial.

Efficiency in patient care

Templates accelerate the gathering of health histories by providing a clear and concise framework for healthcare providers to follow. This efficiency saves time during patient interviews and speeds up decision-making, allowing for quicker interventions.

Educational tool

An HPI template is an excellent educational tool for new healthcare providers or students. It helps them learn what critical information needs to be gathered and how to organize it effectively.

Facilitates comprehensive assessment

The template prompts the healthcare provider to explore various aspects of the patient's condition (such as associated symptoms and exacerbating or relieving factors), ensuring a thorough assessment and laying a solid foundation for diagnosis and treatment planning.

Overall, an HPI template is an invaluable asset found in medical practice every day. It enhances the quality of patient care through improved data accuracy, efficiency, and communication among healthcare providers.

What to do after completing the HPI?

After completing the History of Present Illness (HPI), the next step typically involves conducting a thorough physical examination to assess the patient further. This examination allows healthcare providers to verify symptoms mentioned during the HPI and identify any additional relevant signs.

Based on the findings from the HPI and the physical exam, appropriate diagnostic tests might be ordered to investigate the symptoms more deeply. These tests help to confirm a diagnosis, rule out certain conditions, or monitor the severity of the disease.

This process is crucial, especially in settings like emergency departments or during initial consultations in medical services, in cases where a precise understanding of the patient's condition can significantly impact treatment decisions. This systematic approach ensures that all relevant clinical information is considered before making a final diagnosis or treatment plan.

Why use Carepatron as your clinical documentation software?

Carepatron provides state-of-the-art clinical documentation software that streamlines the creation and management of medical records, including the History of Present Illness (HPI). Designed with efficiency in mind, this software enhances healthcare providers' ability to focus on patient care by minimizing the time spent on administrative tasks. Carepatron's practice management software allows you to access user-friendly features that ensure accurate and comprehensive documentation, essential for effective patient management and care continuity. Discover how Carepatron can transform your clinical documentation today!