How to Document History of Present Illness?

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• How to Document History of Present Illness?

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How to Document History of Present Illness?
Obtaining an accurate history is the critical
first step in to determine about patients
illness. Many times, physicians will be able to
make a diagnosis based on the history of
patient. How an HPI (History of Present Illness)
report is documented? Location This refers to the
exact site where the patient is feeling the pain.
Examples include back pain, sore elbow, cut
on leg, etc. Quality If the patient is
experiencing pain, then the nature of the pain
should be documented. For example
characteristics about the problem. If there is
problem with vision then indicate whether the
patient experiencing blurry vision, foggy vision
or double vision. Severity It represents the
degree of pain or loss of sight. For example
improved, blood sugar 205, intolerable pain, etc.
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How to Document History of Present Illness?
Duration Indicate the duration of the
issue/illness for the patient. You can specify
the date here. For example since childhood,
first noticed a week ago, on and off for several
weeks, etc. Timing This represents the approx.
time like morning/noon, mealtime, etc. For
example intermittent, only in the evening,
etc. Context Indicate if your illness is related
to any activity or circumstances surrounding the
complaint. For example during exercise, after
medication, while standing, etc. Modifying
factors It shows that the effort of the patient
is taking to improve the illness or injury. For
example improves with aspirin, worse when
sitting, etc. Associated signs and symptoms Here
you can indicate any associated signs and
symptoms with the problem such as headache,
tearing, redness, etc.
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How to Document History of Present Illness?
Two Common Types of HPI Reports Brief HPI A
brief HPI is defined as the documentation of one
to three elements of the present
illness. Extended HPI An extended HPI is a
defined as the documentation of four to eight
elements of the present illness. It is important
to add additional data as appropriate to avoid
potential down-coding. However, be aware of
wasting time for recording historical information
which neither contributes to your thought process
nor billing. About Medisys We are a group of
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