History of the present illness
{{Short description|The pertinent information surrounding a patient's history leading to a current illness}}
{{distinguish|Past medical history}}
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI){{cite journal |author=Adler HM |title=The history of the present illness as treatment: who's listening, and why does it matter? |journal=J Am Board Fam Pract |volume=10 |issue=1 |pages=28–35 |year=1997 |pmid=9018660 }} (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Questions to include
Different sources include different questions to be asked while conducting an HPI.
Several acronyms have been developed to categorize the appropriate questions to include.
The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements. An "extended HPI" includes four or more of these elements.[http://www.emrconsultant.com/emr_EMcoding.php Evaluation and Management Coding and Electronic Health Records]{{cite web |url=http://www.usc.edu/health/uscp/compliance/tm6.html#6 |title= Compliance Training Manual|website=www.usc.edu |archive-url=https://web.archive.org/web/20010503032321/http://www.usc.edu/health/uscp/compliance/tm6.html |archive-date=2001-05-03}}
| class="wikitable" |
| CMS
!"OLDCARTS" ! "OPQRST"{{Cite web |url=http://hopperinstitute.com/emt_medical.html |title=Medical Assessment |access-date=2006-09-26 |archive-url=https://web.archive.org/web/20070225123304/http://www.hopperinstitute.com/emt_medical.html |archive-date=2007-02-25 |url-status=dead }}[http://www.alpharubicon.com/med/medaccesshaumanao.htm Learning To Perform a Medical Assessment – Part 1: Quick Medical Assessment] !"LOCATES" ! "COLDER AS" |
|---|
| location
|"L": Location | "R": Region and Radiation |"L" : Location | "L": Location | "L": Location | "L:" Location | "L:" Location |
| quality
|"C": Character | "Q": Quality of the pain |"C": Character | "C": Character | "Q": Quality | "C:" Characteristics | "C": Character |
| |
| | | "R": Radiation | "R": Radiation | see above | "R": Radiation |
| severity
|"S": Severity-how disruptive | "S": Severity |"S": Severity | "S": Severity | "I": Intensity | see above | "S": Severity |
| duration
|"O": Onset "D": Duration | "O": Onset |"T": Time | "T": Time frame | "O": Onset | "O:" Onset | "D:" Duration |
| timing
|"T:" Timing | "T": Time |see above | see above | see above | see above | "O": Onset |
| context
| | |"E": Environment | | | |
| modifying factors
|"A": Aggravating factors "R": Relieving factors | "P": Provocation or Palliation |"A" Alleviating/Aggravating Factors | "E": Exacerbation | "A": Aggravating factors | "A:" Aggravating factors | "E:" Exacerbation |
| |
| | | "A": Alleviation | "A": Alleviating factors | "R:" Remitting factors | "R:" Remitting factors |
| associated signs & symptoms
| | |"O": Other symptoms | "A": associated symptoms | "A": Associated symptoms | see above | "A": Associated symptoms |
Also usable is SOCRATES. For chronic pain, the Stanford Five may be assessed to understand the pain experience from the patient's primary belief system.
See also
References
{{reflist}}
External links
- [http://medicine.ucsd.edu/clinicalmed/history.htm Overview at medicine.ucsd.edu]
- [https://web.archive.org/web/20060830191902/http://medinfo.ufl.edu/year1/bcs96/interv/hpians.html Overview at medinfo.ufl.edu]
{{Medical records}}