Understanding the Importance and Evolution of the History of Present Illness (HPI) in a Medical Practice

Making a diagnosis based on a patient's symptoms and other factors requires keen attention to detail and a bit of investigative work on the part of the healthcare provider. Most illnesses and conditions seen by practitioners are gradual; they've developed over time, often with small signs and symptoms that eventually add up to a more significant problem. Some acute illnesses, like gradual ones, may have had warning signs before onset. The history of present illness (also known as HPI) is an integral piece of the puzzle that aids practitioners in understanding how the illness has developed over time. Piecing together and tracking the progression of these illnesses can help doctors and care providers formulate the best treatment plans based on the broader picture. 

What Is a History of Present Illness?

The HPI is an important part of a patient's medical record. It consists of a set of questions asked by a care provider. When a patient presents with a concern, it may not always be obvious what the root cause of the symptoms might be. These questions center on learning more about the patient's chief complaint to understand the symptoms better and make a diagnosis. 

Depending on the severity of the problem, the systems affected, and other observations made by the practitioner, the questions he or she asks may be expanded upon to ensure pertinent details are not missed. This can be aided by using an HPI that is part of an electronic health record (EHR) system.

How the HPI has Changed the Exam Process

Medicine has grown by leaps and bounds in the last few decades. While the primary exam is still a cornerstone for learning more about a patient, how that exam is conducted has changed. Standardization of the exam procedure allows the examining practitioner and other providers to readily find pertinent information in the patient's record. 

The HPI has helped to further organize health history and current findings into a concise format. By systematically recording information, a practitioner creates a complete picture of the symptoms and events that potentially led to the patient's current health status. Electronic records have further facilitated efficient HPI documentation through a uniform input system. 

What Types of Questions Are Asked for the History of Present Illness?

To help standardize the questions and ensure that all the needed information is obtained, a mnemonic affectionately known as OLD CARTS is frequently used to cover the essential points. Additional questions may be asked to further clarify complex cases, but OLD CARTS is an excellent starting point for obtaining useful information. 

The letters in OLD CARTS stand for:

Onset

When did the symptoms begin? Have they been gradual or acute? Have they been experienced before?

Location

What part(s) of the body is/are being affected? Is there more than one area symptoms are being noticed?

Duration

How long do the symptoms last? Minutes, hours, days, weeks? What is the time before experiencing another episode of the sensation or discomfort? 

Characteristics

What does the symptom feel like? For instance, if they're experiencing pain, is it sharp? Dull? Throbbing? 

Alleviating & Aggravating Factors

Is there anything that helps lessen the symptoms? Did they take anything or undergo any therapies such as massage to help? If so, what? Did the treatment help? Are there any particular triggers that may make them come back or worsen? 

Radiation

This term refers to whether the pain or discomfort radiates to another body part. For instance, if knee pain is experienced, does it travel up in the thigh or down into the calf? It's important to note that in some versions of the mnemonic, the "R" stands for "Relief" and would take the place of "Alleviating" in the prior section. In these cases, the "A" would be "Aggravating."

Timing

When practitioners ask about the symptoms' timing, they hope to learn if the pain is constant or intermittent. Constant pain must be explored further to determine if it stays at the same level or if the patient experiences increases and decreases in severity. In the case of intermittent pain (pain that comes and goes), the healthcare provider needs to ask when it occurs, for example, how many times a week or month it might be experienced. 

Severity

When a patient reports pain, part of the History of Present Illness interview will include a severity rating as experienced by the patient. A scale from one to ten is typically used, with one being mild and ten being the worst pain they can remember experiencing. This question helps reveal how much the symptoms impact the patient and paints a clearer picture of the potential causes. 

Other questions a practitioner might ask during a history of present illness interview include lifestyle — is the patient active or sedentary? Have they recently experienced any falls? Is there any family history of the symptoms they're experiencing? Has a prior diagnosis been made for the symptoms, and if so, was a treatment recommended? Did the treatment work? 

While OLD CARTS primarily addresses pain, HPI can be used to eliminate various symptoms and complaints. The above questions can be modified to fit a practice's needs. For example, an ENT may have different questions than an orthopaedist. The beauty of the HPI is its ability to be tailored to a practice or hospital's needs. 

The History of Present Illness in the Electronic Health Record

The advent of the electronic health record (EHR) has made it easier for practitioners to gather patient information and store it in a central location. Most EHRs have an HPI feature with a routine set of questions already built in. This is convenient for healthcare providers and makes the HPI easy to access by other providers within the practice or hospital. 

In some instances, different questions aside from those found in the OLD CARTS mnemonic will be routinely asked. When this is the case, the flexibility to have those additional questions easily added to the electronic HPI can open up time and eliminate awkward patient notes addendums. 

How TempDev Can Help with HPI in EHRs

NextGen EHR offers robust clinical templates, including a myriad of HPIs. In addition, the NextGen HPI is fully customizable, allowing our customers to add their own which is frequently done to meet a specialty's needs. Our consultants and engineers work closely with our customers to ensure their EHR charting needs are met and exceeded. If you're ready to take your records system to the next level, contact us here or by calling us at 888.TEMP.DEV today to discuss how TempDev can help!