History of Present Illness (HPI) Template with Examples

History of Present Illness (HPI) Template

This comprehensive HPI template helps general practitioners capture detailed patient histories, supporting preliminary assessments, diagnosis, and treatment planning. With Heidi, the AI medical scribe for all clinicians, you can instantly generate history of present illness records that:

• Capture detailed patient history, including symptom onset, severity, and impact on daily life. 
• Identify key symptoms, modifying factors, and potential risk factors to narrow down possible diagnoses.
• Evaluate the likely diagnosis and recommend next steps for treatment and follow-up.
   

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What is an HPI Template?

A History of Present Illness (HPI) template is a structured format used to record the history of a patient’s current medical condition. The HPI details key elements such as the onset of the disease, duration, severity, and associated symptoms.  

HPI templates are essential for gathering and organizing the relevant history of a patient’s current illness. This helps ensure that no important details are missed, and treatment plans are well-informed to provide effective care.

In this article, we’ll provide you with a step-by-step guide and practical tips on how to write an effective HPI, inform you about common HPI documentation mistakes and how you can fix them, and most importantly, provide customizable and AI-compatible HPI templates you can use for your medical practice. 

The Real-World Impact of Diligent HPI Template Documentation

HPI templates are critical for accurate diagnosis and timely care. A recent study estimated that around 80% of medical conditions can be correctly diagnosed by thorough HPI documentation. Additionally, it posits that digital tools can be used to improve doctors’ ability to obtain efficient and high-quality HPI documentation.

A couple of years ago, 65-year-old Alexander Frank Patterson was misdiagnosed with an infection with atypical pneumonia, which caused confusion and hypoglycemia. In reality, he was suffering from bleeding from a duodenal ulcer with a large artery in its base. Six hours after arriving at the hospital, his condition worsened, and he was pronounced dead that evening.

The coroner concluded that there had been a “premature diagnostic closure”, and that the failure of doctors to communicate key information between the care team members led to the fatal misdiagnosis.

Ultimately, the hospital would be subject to medical documentation audits to ensure they meet the requirements of relevant National Safety and Quality Health Service (NSQHS) standards.

This case underscores the importance of diligent and thorough HPI documentation for preventing diagnostic errors.  

How to Write an Effective HPI: Step-by-Step Guide with Examples

While the template lays the groundwork, it’s ultimately up to healthcare providers to follow best practices to ensure effective HPI documentation. Below is our practical, step-by-step guide, along with some tips on how to fill out your HPI template:

1. Start with the Chief Complaint (CC)

Open with a clear, single-line summary of the patient’s reason for seeking care. This is the foundation of the HPI which will set the tone for the rest of the document.

Example:
Patient presents with severe chest pain lasting nearly 2 hours.

2. Structure the HPI Using a Proven Framework

Use the acronym SOCRATES to ensure you’re able to document a complete and organized narrative:

• S - Site: Where is the symptom?
• O - Onset: When did it start?
• C - Character: What does it feel like (e.g., sharp or dull pain)?‍
• R - Radiation: Does it spread to other areas?‍
• A - Associations: Are there other symptoms present?‍
• T - Timing/Time Course: How often does it occur? Has the pain changed over time?‍
• E - Exacerbating/Relieving Factors: What makes the symptom better or worse?‍
• S - Severity: How intense is the pain?

Example - Note that the letters below in bold are only included for practice purposes, not in actual HPI documents:
Central chest pain (S). Sudden onset while climbing stairs at home (O). Tight, crushing sensation (C), radiating to left arm and jaw (R). Reported shortness of breath, sweating, and nausea (A). Continuous for 2 hours without relief (T), and worsens with physical exertion and deep breathing; no relief with rest or antacids (E). Pain rated 8/10 (S).

3. Include Relevant Context and History

Detail any relevant past conditions, as well as current medications and allergies that can potentially complicate treatment plans. Additionally, include the patient’s family history to rule out genetic factors and hereditary conditions.

Outline their social history and lifestyle factors like smoking, alcohol consumption, and the patient’s occupation, to rule out risk factors and other potential underlying cases.

Example:
Medical History - 45-year-old male with a history of hypertension and hyperlipidemia presents with sudden onset of chest pain radiating to the left arm. No previous cardiac arrests but reports of occasional heart palpitations.

Medications - Lisinopril 10 mg daily for hypertension, and atorvastatin 20 mg daily for hyperlipidemia.

Allergies - No known drug allergies.

Family History - Father died of myocardial infarction at age 50, and mother has type 2 diabetes.

Social History - Been smoking at least 1 pack of cigarettes daily for 20 years, and drinks alcohol occasionally. Works a high-stress office job.

4. Focus on Clarity and Brevity

Keep your sentences short and precise, avoid medical jargon unless essential, and stick to a logical order; beginning with the onset before describing the progression. HPI notes are often used to inform emergency and admission notes so they must be able to give a complete picture of the patient’s situation in a few short sentences.

Example:
Sudden onset of sharp chest pain, radiating to the left arm and jaw. Continuous for 2 hours and no relief with rest or antacids.

5. End with a Summary and Next Steps

Conclude the HPI documentation with a concise summary of the key details, and include any working diagnosis or planned testing. A well-written summary improves handoffs and communication between healthcare providers for a quicker, more accurate diagnosis.

Example:
Patient presents with acute chest pain radiating to left arm, onset 2 hours ago. Suspected myocardial infarction. Will order ECG and troponin test. 

HPI Template Example

Here’s a free HPI example in PDF and Google Doc form.

While HPI documentation is critical for helping doctors in emergencies, they are also time-consuming and error-prone when written manually. Fortunately, an AI-powered solution is now available to ensure fast, accurate, and thorough HPI documentations for doctors everywhere.

77% of My Emergency Doctor’s (MED) clinicians immediately adopted Heidi within the first three weeks of its rollout, cutting their average documentation and reporting time from 2 hours to just 20 minutes.

“Heidi is easy to work with, the training required is minimal. And seeing a professional medical summary created after a consult with a patient, which filters out all the unnecessary details and includes clear plans and patient instructions… is a game changer.”  - Tatiana Lowe, Medical Director and FACEM at MED

Easily Complete HPI Templates with Heidi

Heidi is our state-of-the-art AI medical scribe designed to help healthcare providers complete HPI templates in real-time. With your patient’s permission, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your HPI documentation:

• Transcribe – Open Heidi on your computer or mobile device and press Start so Heidi can capture your conversation in the background. For information that you don’t want to verbalize, you can type them under context notes to be considered later.
  
• Customize – After the session, simply select your preferred HPI template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate format!
  
• Transform – After generating your completed HPI templates, you can ask Heidi to give additional documentation including physical exam notes and treatment plans as needed. 

Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our compliance here.

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Free History of Present Illness (HPI) Templates

History of Presenting Complaint Template

This HPI template is a comprehensive digital tool used by general practitioners to document relevant medical histories in patient visits. It captures key points including the onset, duration, and characteristics of the patient’s current condition along with associated symptoms. 

View Template‍

HPI Medical Example Template

This template with an HPI section is designed for emergency medicine specialists. It captures critical patient information including past medical history, habits, medications, and a detailed history of present illness to inform emergency care plans. 

View Template‍

Emergency Medicine HPI Template

This emergency admission template, which includes an HPI section is designed to outline essential patient information during an emergency admission. It covers the reason for presentation, relevant medical history, review of systems, and management en route, among others. 

View Template

FAQs About HPI Templates

What’s the difference between HPI and ROS?

HPI focuses on the information regarding the patient’s current complaint, while review of systems (ROS) performs a broader review of the patient’s bodily systems. The latter aims to uncover additional issues and symptoms even if they’re not directly related to the current complaint. 

How can poor HPI template documentation lead to misdiagnosis or delayed care?

Low-quality HPI notes can result in overlooked details critical to forming an accurate diagnosis. For example, if the clinician fails to take note whether the patient’s chest pain radiates to other parts of their body, a myocardial infarction could be overlooked. This could lead to dangerous delays in treatment. 

Can I tailor Heidi’s HPI templates to my patients’ needs?

Yes! Heidi’s AI-enabled HPI templates can be easily tailored to fit specific patient conditions. We’ve designed Heidi to be highly-intuitive so you can adopt the system and improve your existing process right away. Review our guide on note customization and document management to get started.