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Primary Care Physician
30-45 minutes

History of Present Illness

The HPI template by s10.ai is an all-encompassing resource designed for General Practitioners to meticulously document the History of Present Illness during patient consultations. This template efficiently records critical information such as the onset, duration, and characteristics of the patient's current condition, alongside associated symptoms and pertinent medical history. It also features sections for Review of Systems, Physical Examination, Lab Results, Current Medications, Assessment, and Plan. This organized format guarantees comprehensive documentation, facilitating precise diagnosis and effective treatment planning. Perfect for GPs, this template significantly boosts clinical productivity and patient care when integrated with s10.ai, the AI medical scribe.

4,498 uses
4.9/5.0
D
Dr. Emily Chen
Template Structure

Organized sections for comprehensive clinical documentation

Chief Complaint:
[Describe the primary reason for the patient's visit]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
History of Present Illness (HPI):
[Describe the onset, duration, and characteristics of the current issue]
[Mention any associated symptoms or factors that alleviate or exacerbate the condition]
[Include any relevant past medical history related to the current issue]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Review of Systems (ROS):
[List any positive or negative findings from the review of systems]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Physical Examination:
General appearance: [Describe]
Vital signs: [Mention]
Head, Eyes, Ears, Nose, Throat (HEENT): [Describe findings]
Cardiovascular: [Describe findings]
Respiratory: [Describe findings]
Abdominal: [Describe findings]
Musculoskeletal: [Describe findings]
Neurological: [Describe findings]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Lab Results:
[List any relevant laboratory results]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Current Medications:
[Mention any current medications the patient is taking]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Assessment:
[Provide a summary of the clinical findings and diagnosis]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Plan:
[Outline the treatment plan, including medications, lifestyle changes, and follow-up appointments]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

Chief Complaint:
- The patient reports a persistent cough and difficulty breathing.
History of Present Illness (HPI):
- The cough started about two weeks ago and has been getting worse. The patient describes the cough as dry and mostly occurring at night. Shortness of breath is experienced during physical activity.
- The patient denies having a fever or chest pain but notes that sitting upright provides some relief from the cough.
- The patient has a history of seasonal allergies but no prior respiratory problems.
Review of Systems (ROS):
- Positive for cough and difficulty breathing. Negative for fever, chills, or chest pain.
Physical Examination:
- The patient appears slightly anxious but is not in acute distress.
- Vital signs: Blood pressure 120/80 mmHg, heart rate 78 bpm, respiratory rate 18 breaths per minute, temperature 36.8°C.
- HEENT: Nasal mucosa is slightly swollen, no sinus tenderness.
- Cardiovascular: Heart sounds are normal, no murmurs.
- Respiratory: Mild wheezing heard on auscultation, decreased breath sounds in the lower lobes.
- Abdominal: Soft, non-tender, no organomegaly.
- Musculoskeletal: Normal range of motion, no joint swelling.
- Neurological: Alert and oriented, no focal deficits.
Lab Results:
- Complete blood count (CBC) is within normal limits.
Current Medications:
- Loratadine 10 mg daily for allergies.
Assessment:
- The clinical findings indicate a diagnosis of acute bronchitis, likely worsened by seasonal allergies.
Plan:
- Prescribe an albuterol inhaler for relief of wheezing.
- Advise the patient to increase fluid intake and rest.
- Schedule a follow-up appointment in two weeks to evaluate symptoms.
- Consider referral to an allergist if symptoms continue.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation by providing a structured format for capturing essential medical information. It includes sections for Chief Complaint, History of Present Illness (HPI), Review of Systems (ROS), Physical Examination, Lab Results, Current Medications, Assessment, and Plan. Each section is meticulously crafted to ensure that healthcare professionals can efficiently document patient encounters, enhancing clinical accuracy and improving patient care outcomes. By adopting this template, clinicians can ensure thorough documentation, facilitate better communication among healthcare teams, and optimize patient management strategies. Explore this template to enhance your clinical documentation process today.
Frequently Asked Questions

Common questions about this template and its usage

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History of Present Illness