HPI includes the following elements, in accordance with the 1995 documentation guidelines:
- Location—An area of the body, such as lower right leg, or the site of a problem or symptom, such as a sore throat.
- Duration—The length of time the patient has had the symptom or problem. Examples could include since last week, past three days, three years or last night.
- Severity—The intensity, degree or measure of the symptom or condition. Examples could include the worst pain I’ve ever experienced, pain is 5 on a scale from 1 to 10, not bad or severe.
- Quality—Describe the character or attribute of the symptom or condition. The descriptions can be defined as sharp, dull, throbbing, stabbing, scratchy, etc.
- Context—Surrounding events or what the patient was doing at the time the symptom or problem began. Examples could include falling going up the stairs or left tibia fractured while playing tennis.
- Modifying factor—What the patient has done to alleviate or try to fix the symptoms. Examples could include the patient took ibuprofen, applied an ice pack or used cortisone cream.
- Associated signs and symptoms—Document any additional signs associated with the primary problem, such as indigestion, chest pain, weakness or headache.
- Timing—Document when the symptoms began or occur. Examples could include every three hours, worse at night, hurts all the time or experiences pain every 30 minutes.
Two types of HPI—brief and extended—are distinguished by the amount of detail required to accurately characterize the clinical problem(s). A brief HPI consists of one to three elements, for example: Patient presents with pain in right toe [location] with swelling and burning [quality]—meets two HPI elements.
An extended HPI consists of four or more elements, for example: Patient presents with pain in right toe ([location] with swelling and burning [quality], and pain is a 9 out of 10 [severity]. Patient stated that she took an over-the-counter NSAID [modifying factor] and that the pain gets worse at night [timing]—meets five HPI elements.
In the 1997 guidelines, an alternate documentation requirement redefined the extended HPI for providers to list four or more elements of the HPI, or the status of three or more chronic or inactive conditions. But failure to document the status will negate the opportunity for the physician to receive HPI credit. Instead, this will allow the provider to receive credit only for a past medical history.
Review of System: The ROS consists of a series of questions used to elicit information about additional signs, symptoms or problems currently or previously experienced by the patient. The ROS may be recorded by someone other than the provider, but it is recommended that the provider make reference to the information in their own notes.
