I feel like everyone ends up having their own style of writing even in a medical chart. The HPI is the first section that I usually have new trainees write. I feel like when I first started it’s nice to have some structure then, once you get the hang of things you can tweak it. From working with multiple different scribes and providers everyone has their unique “style” but, this is just how I think about it.
What is an HPI?
HPI stands for history of present illness. This is under the “subjective” section. The history means all of the events that have brought us to this visit. Then, the patient’s story of their symptoms.
While working as a medical scribe trainer this was usually the first section I got people to start writing. One of the biggest struggles I saw for newer scribes was knowing what to include and how to organize the information. This can be especially tricky if the patient jumps around the story a lot. However like I tell everyone this can happen when it is the first time you are telling a story to everyone and the questions asked might not be something the patient has thought of before.
What should I Include?
The old method used to be OLD CARTS which would fulfill the requirements for medical billing.
- O: Onset (when the issue started)
- L: Location (where is it located, this is usually easiest for pain or rash)
- D: Duration (How often is it here? All of the time? Come and go? Triggered)
- C: Characteristics (Description of symptom for pain; burning, sharp, throbbing)
- A: Aggravating factors (What makes it worse?)
- R: Relieving factors (What makes it better?)
- T: Treatments (What have they tried?)
- S: Severity (How bad is it?)
Even though we don’t necessarily need these values for billing and I do not necessarily put the information in this order, it is night to have a category for the information.
Organizing HPI
My goal when organizing and HPI is a generalized sentence that tell you what the patient is here for:
“Patient is a 50 y.o male who presents to clinic for evaluation of back pain x days.”
I feel like these sentences help with telling just who is the patient and what are we seeing them for?
The next question is what is going on? This section should help us illustrate what is going on. This includes the onset, duration, location, characteristic, severity, aggravating, and relieving factors. I usually try to organize this further for example for back pain:
“Patient reports intermittent back pain present in the evening. (timing) Pain is located over the mid lower back without radiation and is described as an ache. Pain is rated a 4/10 in severity and nothing in particular makes it better or worse. ”
What can we try for them? Depending on how much the patient has tried before they came into their visit. Sometime I make a separate paragraph for treatments, over the counter medication. Sometimes, I make a separate paragraph for treatments, over-the-counters, and specialists they have seen with their outcomes:
” Patient has tried heat, ibuprofen and chiropractor adjustments. Heat and ibuprofen provide transient relief. Chiropractic adjustments provided no relief.”
Template
I do have a basic template for my HPI that is helpful when first starting out. Then, as I just got used to organizing my HPI I can just write on the fly. I do like the template it’s kind of like a mad lib. I have multiple for different types of complains but, we can get into those later.
Patient is a (age) (sex) who presents to clinic for evaluation of (chief complaint) x (onset).
Patient reports
Admits to
Denies
Patient has tried ____ with ___ relief.