The HPI is a chronological description of the development
of the patient's present illness from the first sign and/or
symptom or from the previous encounter to the present. It
should provide pertinent details about the reason for the
encounter. Types of details include:
For symptoms: location, quality, severity, duration, timing,
context, modifying factors including medications, associated
signs and symptoms etc.
For follow up of a previously diagnosed problem: changes
in condition since the last visit, compliance with the treatment
plan etc.
For patients on multiple medications or whose primary reason
for the visit is for medication management: review of compliance,
effectiveness of medications, side effects and complications
from medications, verification of medication name, dosage
and frequency.
For patients with one or more chronic conditions: a status
of those conditions and/or the functional status of the
patient (e.g., continence, managing medications).
Brief and extended HPIs are distinguished by the amount
of detail needed to accurately characterize the clinical
problem(s).
· DG: A brief HPI consists of: documentation of
the chief complaint(s) or reason(s) for the encounter
as well as 1 - 3 pertinent details about at least one
the presenting problem/illness(es) or the status of 1
chronic or inactive condition
· DG: An extended HPI documents the chief complaint(s)
or reason(s) for the encounter as well as 4 or more details
about at least one the presenting problem/illness(es)
or the status of at least 3 chronic or inactive conditions.
