HISTORY OF PRESENT ILLNESS (HPI)

History

The chart below depicts the elements required for each type of history. More information on the activities comprising each of these elements is provided on pages 5–10. To qualify for a given type of history, all four elements indicated in the row must be met. Note that as the type of history becomes more intensive, the elements required to perform that type of history also increase in intensity.

For example, a problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).


Elements Required for Each Type of History

TYPE OF HISTORY          CC           HPI         ROS          PFSH

Problem Focused       Required         Brief         N/A       N/A

Expanded Problem Focused        Required           Brief     Problem Pertinent         N/A

Detailed        Required         Extended         Extended         Pertinent

Comprehensive          Required          Extended        Complete            Complete


While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history depends on clinical judgment and the nature of the presenting problem.

Chief Complaint

A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words.

For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC.

History of Present Illness

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

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

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). .

A brief HPI consists of one to three elements of the HPI. 
• DG: The medical record should describe one to three elements of the present illness (HPI). 

An extended HPI consists of four or more elements of the HPI.

• DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.

HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

* Location (example: left leg);

* Quality (example: aching, burning, radiating pain);

* Severity (example: 10 on a scale of 1 to 10);

* Duration (example: started 3 days ago);

* Timing (example: constant or comes and goes);

* Context (example: lifted large object at work);

* Modifying factors (example: better when heat is applied); and

* Associated signs and symptoms (example: numbness in toes).

The two types of HPIs are brief and extended.

A brief HPI includes documentation of one to three HPI elements.

In the following example, three HPI elements – location, quality, and duration – are documented:

* CC: Patient complains of earache.

* Brief HPI: Dull ache in left ear over the past 24 hours.

No comments:

Medical Billing Popular Articles