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Primary Care Physician
30-45 minutes

Detailed Template for Present Illness History (HPI)

The Comprehensive History of Present Illness (HPI) Template is a vital resource for general practitioners seeking to meticulously document patient histories. This template enables healthcare providers to record an in-depth account of a patient's symptoms, covering aspects such as onset, location, duration, and severity, along with associated symptoms and risk factors. It supports the development of an initial assessment and guides the planning of subsequent diagnostic and treatment steps. Particularly beneficial for general practitioners handling diverse medical conditions, this template ensures a holistic approach to patient care. Perfectly compatible with s10.ai, it optimizes the documentation process, boosting clinical efficiency.

4,722 uses
4.9/5.0
E
Ethan Caldwell
Template Structure

Organized sections for comprehensive clinical documentation

Patient Name: [Enter Patient Name]
Date of Birth (DOB): [MM/DD/YYYY]
Medical Record (MR) : [Enter MR Number]
Date of Visit: [MM/DD/YYYY]
Primary Provider: [Enter Provider Name, Credentials, and Specialty]
Chief Complaint (CC):
[Describe the main symptom(s) or concern(s) prompting the patient to seek medical attention. Include symptom duration and any specific details about onset.]
HISTORY OF PRESENT ILLNESS (HPI) – DETAILED
Onset: [Detail when symptoms started, including approximate time frame. Indicate if onset was sudden or gradual, and whether symptoms have worsened or remained stable.]
Location: [Specify the anatomical location of symptoms. If applicable, note whether symptoms are localized or radiate to other areas.]
Duration: [Describe how long the symptoms have been present and whether they are continuous or intermittent. Indicate any worsening over time and variations in symptom intensity throughout the day.]
Character/Quality: [Provide a description of the symptom’s nature, including descriptors such as sharp, dull, burning, tightness, or pressure. For cough, describe productive vs. non-productive and sputum characteristics, if applicable.]
Severity: [Rate the severity of symptoms on a numerical scale if possible (e.g., 1-10). Include impact on daily activities, sleep, and overall function.]
Modifying Factors: [Identify what makes symptoms better or worse, including rest, medications, physical activity, or environmental factors. Note any home remedies attempted and their effectiveness.]
Associated Symptoms: [List any other symptoms that accompany the chief complaint, including systemic, respiratory, cardiovascular, gastrointestinal, neurological, or musculoskeletal symptoms. Specify if symptoms are worsening, improving, or unchanged.]
Context: [Include any relevant preceding events, such as recent illness, travel, exposure to allergens or infections, lifestyle changes, or new medications. Also note if similar symptoms have occurred previously and how they were managed.]
Risk Factors: [Document relevant patient risk factors that could contribute to the current condition, including medical history, smoking, occupational exposure, family history, or any relevant lifestyle factors.]
Impact on Daily Life: [Describe how symptoms affect the patient’s daily activities, mobility, sleep, work, or ability to perform routine tasks.]
Additional Notes for Differential Consideration:
Pain-Related Complaints (OLDCARTS Analysis): [If applicable, describe onset, location, duration, character, aggravating/alleviating factors, radiation, timing, and severity of pain. Note response to medications or position changes.]
Respiratory Symptoms: [Include details on cough, sputum characteristics, shortness of breath, wheezing, and history of exacerbations. Note any changes in baseline respiratory function.]
Gastrointestinal Symptoms: [Describe any nausea, vomiting, diarrhea, constipation, heartburn, or reflux symptoms. Note any associated abdominal pain or bloating.]
Neurological Symptoms: [Document dizziness, headaches, vision changes, weakness, or recent falls.]
Cardiac Symptoms: [Include palpitations, chest pain, syncope, swelling, or any prior history of cardiovascular conditions.]
PRELIMINARY ASSESSMENT & NEXT STEPS
Likely Diagnosis: [Provide an initial diagnostic impression based on history and symptoms. List possible differential diagnoses to consider.]
Plan: [List the next steps for evaluation and treatment, including orders for imaging, laboratory tests, medication adjustments, specialist referrals, and follow-up recommendations.]
Physician Signature:
[Enter Physician Name, Credentials]
[Enter Healthcare Facility Name]
Date: [MM/DD/YYYY]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Patient Name: John Doe  
Date of Birth (DOB): 05/14/1980  
Medical Record (MR) : 123456789  
Date of Visit: 01/11/2024  
Primary Provider: Dr. Emily Smith, MD, General Practitioner  
Chief Complaint (CC):  
Ongoing cough and difficulty breathing for the past two weeks, with symptoms intensifying over the last few days.  
HISTORY OF PRESENT ILLNESS (HPI) – DETAILED  
Onset: Symptoms started about two weeks ago, initially mild but have progressively worsened.  
Location: Symptoms are mainly respiratory, with the cough originating from the chest area.  
Duration: Symptoms have persisted for two weeks, with increased severity in the evenings.  
Character/Quality: The cough is dry and non-productive, accompanied by a feeling of tightness in the chest.  
Severity: Severity rated at 6/10, affecting sleep and daily activities.  
Modifying Factors: Symptoms slightly improve with rest and over-the-counter cough syrup, but worsen with physical exertion.  
Associated Symptoms: Occasional headaches and mild fatigue, no fever or chills.  
Context: Recently returned from a business trip to a high-altitude area. No known exposure to allergens or infections.  
Risk Factors: History of mild asthma, non-smoker, no significant family history of respiratory conditions.  
Impact on Daily Life: Difficulty performing routine tasks and reduced exercise tolerance.  
Additional Notes for Differential Consideration:  
Pain-Related Complaints (OLDCARTS Analysis): Not applicable.  
Respiratory Symptoms: Persistent dry cough, shortness of breath, no wheezing noted.  
Gastrointestinal Symptoms: None reported.  
Neurological Symptoms: Occasional mild headaches.  
Cardiac Symptoms: No palpitations or chest pain reported.  
PRELIMINARY ASSESSMENT & NEXT STEPS  
Likely Diagnosis: Viral bronchitis with consideration for asthma exacerbation.  
Plan: Order chest X-ray and pulmonary function tests. Prescribe inhaler for symptom relief. Recommend follow-up in two weeks or sooner if symptoms worsen.  
Physician Signature:  
Dr. Emily Smith, MD  
s10.ai  
Date: 01/11/2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation by capturing essential details for accurate diagnosis and treatment planning. With fields for patient demographics, chief complaints, and a detailed history of present illness (HPI), this template ensures thorough documentation of symptom onset, location, duration, and severity. It also includes sections for modifying factors, associated symptoms, and context, providing a holistic view of the patient's condition. Additional notes for differential consideration cover pain, respiratory, gastrointestinal, neurological, and cardiac symptoms, aiding in precise differential diagnosis. The preliminary assessment and next steps section guides clinicians in forming a likely diagnosis and outlines a clear plan for further evaluation and treatment. By adopting this template, healthcare providers can enhance clinical efficiency, improve patient care, and ensure comprehensive medical records.
Frequently Asked Questions

Common questions about this template and its usage

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