How to write hpi?

Key Components

Contributory Factors

Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors.  The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the history table must be met. A chief complaint is indicated at all levels.

• Has a starting point (i.e. “the patient was in her usual state of health until 5 days prior to admission.).
• Has appropriate flow, continuity, sequence, and chronologic order.

The written History and Physical (H&P) serves several purposes:

The H&P is not:

Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced physicians. Several sample write-ups are presented at the end of this section to serve as reference standards.

The core aspects of the H&P are described in detail below.

Chief Concern (CC): One sentence that covers the dominant reason(s) for hospitalization. While this has traditionally been referred to as the Chief Complaint, Chief Concern may be a better description as it is less pejorative and confrontational sounding.

The HPI should provide enough information to clearly understand the symptoms and events that lead to the admission. This covers everything that contributed to the patient's arrival in the ED (or the floor, if admission was arranged without an ED visit). Events which occurred after arrival can be covered in a summary paragraph that follows the pre-hospital history.

A commonly used pneumonic to explore the core elements of the chief concerns is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, and Significance.

Some HPIs are rather straight forward. If, for example, you are describing the course of a truly otherwise healthy 40-year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that time frame alone. Writing HPIs for patients with pre-existing illness(es) or a chronic, relapsing problems is a bit trickier. In such cases, it’s important to give enough relevant past history "up front," as having an awareness of this data will provide the contextual information that allows the reader to fully understand the acute issue. If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, an inclusive format would be as follows:

That's a rather complicated history. However, it is obviously of great importance to include all of the past cardiac information "up front" so that the reader can accurately interpret the patient's new symptom complex. The temporal aspects of the history are presented in an easy to follow fashion, starting with the most relevant distant event and then progressing step-wise to the present.

From a purely mechanical standpoint, note that historical information can be presented as a list (in the case of Mr. S, this refers to his cardiac catheterizations and other related data). This format is easy to read and makes bytes of chronological information readily apparent to the reader. While this data is technically part of the patient's "Past Medical History," it would be inappropriate to not feature this prominently in the HPI. Without this knowledge, the reader would be significantly handicapped in their ability to understand the patient's current condition.

Knowing which past medical events are relevant to the chief concern takes experience. In order to gain insight into what to include in the HPI, continually ask yourself, "If I was reading this, what historical information would I like to know?" Note also that the patient's baseline health status is described in some detail so that the level of impairment caused by their current problem is readily apparent.

The remainder of the HPI is dedicated to the further description of the presenting concern. As the story teller, you are expected to put your own spin on the write-up. That is, the history is written with some bias. You will be directing the reader towards what you feel is/are the likely diagnoses by virtue of the way in which you tell the tale. If, for example, you believe that the patient's chest pain is of cardiac origin, you will highlight features that support this notion (e.g. chest pressure with activity, relieved with nitroglycerin, preponderance of coronary risk factors etc.). These comments are referred to as "pertinent positives." These details are factual and no important features have been omitted. The reader retains the ability to provide an alternative interpretation of the data if he/she wishes. A brief review of systems related to the current complaint is generally noted at the end of the HPI. This highlights "pertinent negatives" (i.e. symptoms which the patient does not have). If present, these symptoms might lead the reader to entertain alternative diagnoses. Their absence, then, lends support to the candidate diagnosis suggested in the HPI. More on the HPI can be found here: HPI.

Occasionally, patients will present with two (or more) major, truly unrelated problems. When dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the HPI. If so, present them as separate HPIs, each with its own paragraph.

This includes any illness (past or present) that the patient is known to have, ideally supported by objective data. Items which were noted in the HPI (e.g. the cardiac catheterization history mentioned previously) do not have to be re-stated. You may simply write "See above" in reference to these details. All other historical information should be listed. Important childhood illnesses and hospitalizations are also noted.

Detailed descriptions are generally not required. If, for example, the patient has hypertension, it is acceptable to simply write "HTN" without providing an in-depth report of this problem (e.g. duration, all meds, etc.). Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension.

Also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. It is not uncommon for misinformation to be perpetuated when past write-ups or notes are used as the template for new H&Ps. When this occurs, a patient may be tagged with (and perhaps even treated for) an illness which they do not have! For example, many patients are noted to have Chronic Obstructive Pulmonary Disease (COPD). This is, in fact, a rather common diagnosis but one which can only be made on the basis of Pulmonary Function Tests (PFTs). While a Chest X-Ray and smoking history offer important supporting data, they are not diagnostic. Thus, "COPD" can repeatedly appear under a patient's PMH on the basis of undifferentiated shortness of breath coupled with a suggestive CXR and known smoking history, despite the fact that they have never had PFTs. So, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.

Past Surgical History (PSH):

All past surgeries should be listed, along with the rough date when they occurred. Include any major traumas as well.

Medications (MEDS):

Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage, frequency and adherence should be noted.

Allergies/Reactions (All/RXNs):

Identify the specific reaction that occurred with each medication.

Social History (SH): This is a broad category which includes:

Family History (FH): This should focus on illnesses within the patient's immediate family. In particular, identifying cancer, vascular disease or other potentially heritable diseases among first degree relatives

Obstetrical History (where appropriate):

Included the number of pregnancies, live births, duration of pregnancies, complications. As appropriate, spontaneous and/or therapeutic abortions. Birth control (if appropriate).

Review of Systems (ROS): As mentioned previously, many of the most important ROS questions (i.e. pertinent positives and negatives related to the chief concern) are generally noted at the end of the HPI. The responses to a more extensive review, covering all organ systems, are placed in the "ROS" area of the write-up. In actual practice, most physicians do not document an inclusive ROS. The ROS questions, however, are the same ones that are used to unravel the cause of a patient's chief concern. Thus, early in training, it is a good idea to practice asking all of these questions so that you will be better able to use them for obtaining historical information when interviewing future patients. A comprehensive list can be found here: ROS

Physical Exam: Generally begins with a one sentence description of the patient's appearance. Vital Signs: HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, thyroid. Lymph Nodes: Lungs: Cardiovascular: Abdomen: Rectal (as indicated): Genitalia/Pelvic: Extremities, Including Pulses:

Neurologic:

Lab Results, Radiologic Studies, EKG Interpretation, Etc.:

Assessment and Plan:

It's worth noting that the above format is meant to provide structure and guidance. There is no gold standard, and there’s significant room for variation. When you're exposed to other styles, think about whether the proposed structure (or aspects thereof) is logical and comprehensive. Incorporate those elements that make sense into future write-ups as you work over time to develop your own style

SAMPLE WRITE UP #1

ADMISSION NOTE

CC: Mr. B is a 72 yo man with a history of heart failure and coronary artery disease, who presents with increasing shortness of breath, lower extremity edema and weight gain.

HPI: His history of heart failure is notable for the following:

Over the past 6 months he has required increasing doses of lasix to control his edema. He was seen 2 weeks ago by his Cardiologist, Dr. Johns, at which time he was noted to have worsening leg and scrotal edema. His lasix dose was increased to 120 bid without relief of his swelling.

Over the past week he and his wife have noticed a further increase in his lower extremity edema which then became markedly worse in the past two days. The swelling was accompanied by a weight gain of 10lb in 2 days (175 to 185lb) as well as a decrease in his exercise tolerance. He now becomes dyspneic when rising to get out of bed and has to rest due to SOB when walking on flat ground. He has 2 pillow orthopnea, but denies PND.

Denies CP/pressure, palpitations or diaphoresis. Occasional nausea, but no vomiting. He eats normal quantities of food but does not salt or fluid intake. He also admits to frequently eating canned soup, frozen meals, and drinking 6-8 glasses liquid/day. He has increased urinary frequency, but decreased total amount of urine produced. He denies urinary urgency, dysuria or hematuria. He has not noted cough, sputum, fever or chills. He states he has been taking all prescribed medications on most days – missing a few (? 2-3) doses a week.

SAMPLE WRITE-UP #2

ADMISSION NOTE CC: Mr. S is a 65-year-old man who presents with 2 concerns: 1. Acute, painless decline in vision 2. Three day history of a cough.

HPI: 1. Visual changes: Yesterday morning, while eating lunch, the patient had the sudden onset of painless decrease in vision in both eyes, more prominent on the right. Onset was abrupt and he first noted this when he "couldn't see the clock" while at a restaurant. He also had difficulty determining the numbers on his cell phone. He denied pain or diplopia. Did not feel like a “curtain dropping” in front of his eyes. He had nausea and vomiting x2 yesterday, which has resolved. He did not seek care, hoping that the problem would resolve on its own. When he awoke this morning, the same issues persisted (no better or worse) and he contacted his niece, who took him to the hospital. At baseline, he uses prescription glasses without problem and has no chronic eye issues. Last vision testing was during visit to his optometrist 2 year ago. Notes that his ability to see things is improved when he moves his head to bring things into better view. Denies dizziness, weakness, headache, difficulty with speech, chest pain, palpitations, weakness or numbness. No history of atrial fibrillation, carotid disease, or heart disease that he knows of.

2. Cough: Patient has history of COPD with 60+ pack year smoking history and most recent PFT's (2016) consistent with moderate disease. Over the past few days he has noted increased dyspnea, wheezing, and sputum production. Sputum greenish colored. He uses 2 inhalers, Formoterol and Tiotropium every day and doesn’t miss any dosages. He was treated with antibiotics and prednisone a few years ago when he experienced shortness of breath. He has not had any other breathing issues and no hospitalizations or ED visits. Denies hemoptysis, fevers, orthopnea, PND, chest pain or edema.

ED course: given concern over acute visual loss and known vascular disease, a stroke code was called when patient arrived in ER. Neurology service evaluated patient and CT head obtained. Data was consistent with occipital stroke, which occurred > 24 hours ago. Additional details re management described below.

One of my first projects as Program Director was to codify the “Yale Way,” our system for note writing and presenting on rounds. The Yale Way isn’t unique to Yale, of course; other institutions use the same method, more or less. But codification works. It ensures we all speak the same language and tell stories that are thorough, concise, efficient, lucid, and easy to follow.

This is the time of year to establish good habits, so with that in mind, I offer these notes on notes:

Baker’s dozen. Seniors- remember to attach a succinct addendum to all Intern H&Ps. You contributed to the patient’s workup. We need to see your thoughts.

This list is incomplete, of course, and I’d love to hear your ideas. Remember, we can’t take great care of our patients if we don’t communicate well. Look over your notes. Make them memorable. Things of beauty. And think before you sign.

With that, I’m off to join my Fitkin team.

Mark

*Why do we call it the “past” medical history? Is there a “future” medical history?

PS Wriggling by me yesterday on a climb up East Rock: