Tuesday, 9 October 2012

History of Present Illness

HPI - One of the main component of Clinical History.

What is an HPI ?

The history of present illness (HPI) is a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms significantly related to the presenting problem(s).

The HPI:

  • Further defines and clarifies the CC as related to the nature of the presenting problem.
  • Expands upon the CC or reason for the encounter and supports the medical necessity of the service.
  • Provides information needed to accurately characterize and clarify the clinical presenting problem.


    A brief HPI consists of 1-3 elements and an extended HPI consists of 4 or more elements or the status of at least 3 chronic or inactive conditions. Below are the elements of an HPI and a brief description of the information included in each:

    • Location describes where on the body the symptom is occurring.
    • Quality is the character of the symptom (burning, throbbing, tingling, stabbing, and fullness).
    • Severity is a rank of the symptom/pain on a scale of 1-10. Severity can also be described with terms like severe, slightly, worst I’ve ever had.
    • Duration describes how long the symptoms/pain has been present or how long it lasts when the patient has it (hours, days, weeks, months).
    • Timing describes when the pain/symptom occurs (night, after meals, before meals, after I take medication, after or during exercise, number of occurrences or frequencies).
    • Context is the situation associated with the pain/symptom (dairy products, big meals, stair climbing, and injured ankle playing basketball).
    • Modifying factors are things done to make the symptom/pain worse or better (if I eat spicy food I get heartburn but if I drink milk then the pain isn’t as bad; I have migraines but if I lie down in a quiet room with an ice pack on my head it modifies the pain, etc.).
    • Associated signs and symptoms describe the symptom/pain and other things that happen when this symptom/pain occurs (chest pain leads to shortness of breath, headache leads to vision constriction).

     

  • Documentation guidelines

    For any EMR Product, “Evaluation and Management Services guide” document is the bible to develop the patient encounter module. This link has the latest version from the Medicare. if that link is broken, you can download from file factory here.

    E/M Level of HPI:

    The level of HPI documented may be determined by either of two methods:

    1. The number of HPI elements that are needed to characterize the clinical condition, and are included in the document. The possible elements are: duration, severity, location, quality, timing, context, associated signs and symptoms, and modifying factors.

    a. When the document is scored by this method, one of two HPI levels may be chosen:

    • A brief HPI: This consists of an HPI that contains one to three elements. e.g., “Three day history of severe headache” captures duration, location and severity. If no additional elements are documented, then this would be regarded as a brief HPI.
    • An extended HPI: This consists of an HPI that contains 4 or more elements. e.g., “Three day history of severe, throbbing headache with associated photophobia” records duration, location, quality, severity and associated signs and symptoms.

    2. The second method of determining the level of HPI does not include analysis of the HPI elements above, but rather is used when the HPI contains “the status of at least three chronic or inactive conditions.1” In this situation; the HPI is considered to be at the extended level. The following is an example of an HPI that contains three chronic conditions and their statuses:

    Example: The patient has a history of diabetes, hypertension, and hyperlipidemia. Her blood sugars have been well-controlled on diet and oral hypoglycemic agents. The patient's blood pressures have fluctuated significantly based on the patient diary and are suboptimally controlled on her current regimen. The patient's most recent LDL was less than 100 and the patient is currently taking 40 mg of Lipitor per day.


    Elements used in  HPI:

    The Centers for Medicare and Medicaid Services (CMS) recognizes the following HPI elements:

    • location,
    • quality,
    • severity,
    • duration,
    • timing,
    • context,
    • modifying factors, and
    • associated signs and symptoms

    image

    You can also download this document to see more examples for HPI

    Clinical Examples for HPI:
    This link contains some example of HPI for different Levels

    Modern way of recording HPI:
    http://www.modmed.com/

    HPI Documentation Examples

    This is a 78-year-old white female with multiple complaints. She has a history of chronic sinusitis, esophagitis, a fibromyalgia-type syndrome, and depression. She complains today of continued problems with pain in the left cheek and preauricular area, especially in the morning. The pain gets very intense at times. She also has a great deal of postnasal drainage which gives her a sour feeling in her stomach. She also complains of some dizzy spells over the last few months, usually when she is working around the house. These are associated with some sweating and nausea. She has not ever had any loss of consciousness. She also complains of recurrent problems with constipation, especially over the last three months. She has been using Correctol. This tends to give her runny stools for a day and then she has constipation again the next day. She has tried taking Colace. This was not helpful.

     

    This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia. Past Medical History: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.

     

    This is a 59-year-old, right-handed woman with a history of hypertension, schizophrenia, and a fallopian ovarian tumor resecte surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of difficulty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision difficulty swallowing or palpitations. She reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT scan at that time showed bilateral basal ganglion infarcts. Carotid duplex then showed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose.

    HPI Template

    1.1. Onset

    a) When did the Symptoms Start ?
    Choices (Multiple)
    Yesterday, several days ago, last week, several weeks ago , last month, several months ago , last year

    Sentence Format:
    Symptoms started <Answer>

    Example
    Symptoms Started Yesterday

    1.2. Timing

    b) How often do the symptoms occur?

    Choices (Multiple)

    About once a minute, Every few minutes , About once an hour, Every few hours , About once a day , Every few days , About once a week , Every few weeks , About once a month , About once a year , Every few years, Constantly , Do not know

    Sentence Format:

    Symptoms occur <Answer>

    Example

    Symptoms Occur every few minutes.

    Patient unsure about frequency of occurrence of symptoms . (Sample when patient says Do not know)

    c) Do symptoms occur at certain times?

    Choices (Multiple)

    In the morning, In the afternoon, In the Evening, Bedtime , At night , At Home , At work, Seasonal, In the winter, In the spring , In the Summer, Do not know, No, Watching TV, Sleeping , Eating , After eating, Driving car, Stress

    Sentence Format:

    Symptoms occur <Answer>

    Example

    Symptoms Occur in the morning.

    Patient unsure about when symptoms occur. (Sample when patient says Do not know)

    Symptoms do not occur at any specific time (Sample When Patient Says No)

    d) Is it sudden or gradual?

    Choices (Single)

    Sudden, gradual, other

    Sentence Format:

    Symptoms occur Suddenly or Gradually

    1.3. Modifying Factors

    a) What makes it worse ?

    Choices (Multiple)

    Nothing, Medicine, Rest, Exercise , Eating , Sleeping, Sitting, Standing, Lying , Exertion , Do not know

    Sentence Format:

    <answer> makes it worse

    Example

    Sitting makes it worse

    b) What makes it better ?

    Choices (Multiple)

    Nothing, Medicine, Rest, Exercise , Eating , Sleeping, Sitting, Standing, Lying , Exertion , Do not know

    Sentence Format:

    <answer> makes it better

    Example

    Sleeping makes it better.

    c) Have you taken any medicine for it ?

    Yes/No Type

    Sentence Format:

    Patient has taken medicine

    Patient has not taken any medicine

    1.4. Severity

    a) How severe are the symptoms ?

    Choices (Multiple)

    Moderate, Severe, Getting better, Getting worse, Does not interfere with life, Mildly interferes with life, Moderately interferes with life, Do not Know

    Sentence Format:

    Patient indicates symptoms <Answer>

    Example

    Patient indicates symptoms getting better

    b) Does it force you to sit down , lie down, slow down ?

    Choices (Multiple)

    Sit down, Lie down, other, slow down

    1.5. Character

    a) When does it Happen ?

    Choices (Multiple)

    Exertion, stress, eating, sleeping, sitting, lying, walking more than 1 mile, walking more than 2 blocks, standing, other, rest

    Sentence Format:

    Comma separated answers

    Example

    b) What is the quality ?

    Choices (Multiple)

    Sharp, dull, ache, burning, stinging, stabbing, tightness, pressure, heaviness, weight , pin prick, numbness, Thumping, Flip Flop, cannot describe

    Sentence Format:

    Patient indicates the following are associated signs for the problem

    Example

    Patient indicates the following are associated signs for the problem; Severe sweating, fever.

    1.6. Associated Signs

    a) What are the associated signs and symptoms?

    Choices (Multiple)

    dizziness breathlessness, severe sweating, nausea, palpitations, swollen legs, passing out, shortness of breath, fever , fatigue, blurred vision

    Sentence Format:

    Patient indicates the following are associated signs for the problem

    Example

    Patient indicates the following are associated signs for the problem; Severe sweating, fever.

    1.7. Alleviating factors

    a) What makes it better?

    Choices (Multiple)

    Rest, exercise, sitting, sleeping, lying, other

    Sentence Format:

    <Answer> makes it better

    Example

    Rest makes it better

    b) Have you taken medicine for it?

    Choices (Single)

    has taken medicine

    has not taken medicine

    Sentence Format:

    <Answer>

    Example

    Has Taken medicine

    c) What is the medicine?

    Free form Text

    1.8. Duration

    a) How long did it last??

    Choices (Multiple)

    Seconds, Minutes, Hours, Days, Weeks, Months, Years, Constant, Do not know

    Sentence

    The current problem has been for the past 1 years

    1.9. Location/Radiation

    a) Does it Radiate ?

    Yes/No

    b) Where it Radiate ?

    Free Form Text

     

    EMR – HPI Implementation.

    Let me summarize how we can record HPI in the EMR and what are the features should be in the product. The following derived from my EMR Product development experience.

    On the Administration side.

    In the EMR Administration, we should have master (template) for creating HPI. Questions asked under the each HPI elements may differ by Chief complain/Specialty of the doctor. However, we should have option creating new HPI Template and create HPI Elements under each template and set of questions under each HPI Elements.

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