Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

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Components of the History of Present Illness

The components of the History of Present Illness (HPI) are:

1. Location. This item refers to where in the body is the issue localized. Issues can be unilateral, bilateral, right or left, in addition to the region of the body where the problem is.

2. Quality. The quality of a problem is a descriptor that is being assigned to it. For example: If pain is described, it could be dull, sharp, throbbing, etc.

3. Severity. This refers to some sort of quantification of the magnitude of the issue. It could be “mild, moderate or severe”, or it could be a numeric scale.

4. Duration. This item looks to establish the length of time that he problem has been present.

5. Timing. The timing of a problem is its relationship with time. By looking for this item in a problem, a relationship with the time of the day is looked for. For example: if the timing of a discomfort is evaluated, is it worse in the morning, afternoon or evening?

6. Context. This refers to the association of the problem with a particular activity or circumstance.

7. Modifying factors. This item looks to find activities or situations that have an effect (positive or negative)can the problem.

8. Associated signs and symptoms. If the problem is generating other issues, they can be noted as part of this item.

Example

The patient is a 68 year old gentleman who complains of epigastric abdominal pain (location), which began four days ago and has remained persistent (duration). This pain has been more intense in the afternoons (timing), after meals (context). The pain is described as “a colic” (quality) and has reached a nine on a scale of one to ten (severity). It is associated with nausea and shortness of breath (associated signs and symptoms)and relieved by food avoidance (modifying factors).

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness”, SMO Blog (blog). March 29, 2020. https://hive.blog/hive-122108/@secondmedicalop/clinical-documentation-improvement-series-16-evaluation-and-management-documentation-1-components-of-the-history-of-present

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Substance Dependence and Associated Conditions.

- Clinical Documentation Improvement Series #7. Inpatient versus Observation

- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”

- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...

- Clinical Documentation Improvement Series #10. Documenting Pneumonia

- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…

- Clinical Documentation Improvement Series #12. Documentation of Acute Kidney Failure

- Clinical Documentation Improvement Series #13. Documenting Liver Failure

- Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1

- Clinical Documentation Improvement Series #15. General Advise (Tip #2)

Picture downloaded from istockphoto.com under a standard license Author: Dragonimages