History of Present Illness

The History of Present Illness (HPI) is used to describe the status of the symptoms or clinical problems from time of onset or since the previous encounter with the physician.  Some form of HPI is required for each level of care for every type of E/M encounter.  For follow-up visits, it is acceptable to call the HPI an “Interval History.”  

Both the 1995 and 1997 E/M guidelines allow the HPI to be completed by using the so-called HPI elements which are used to further describe a specific somatic complaint (e.g. chest pain).  In clinical settings where there is no such complaint from the patient, the 1997 E/M guidelines (but not the 1995 rules!) offer the option of completing the HPI by commenting on the status of at least three chronic or inactive problems. 

HPI Elements: The following eight elements may be used to characterize a specific somatic complaint:  

1. Location

2. Quality

3. Severity

4. Duration

5. Timing

6. Context

7. Modifying Factors

8. Associated Signs and Symptoms

There are two levels of HPI:

1. Brief HPI: Requires one to three HPI elements

2. Extended HPI: Requires four HPI elements or the status of three chronic problems if using the 1997 E/M guidelines (but not if using the 1995 rules!)

Example using the HPI elements.     

An Extended HPI for a patient being admitted from the ER with chest pain

CC: Chest pain

HPI: Patient complains of chest pain (location), which began three hours ago (duration).  Pain has been off and on since that time with each episode lasting two to three minutes (timing).  The pain is described as “crushing” (quality) and at times is rated as an eight on a scale of one to ten (severity).  The pain occurs with minimal exertion (context) and is associated with nausea and shortness of breath (associated signs and symptoms).  The pain was relieved with sublingual NTG in the ambulance (modifying factors).

Example using the status of chronic or inactive problems.      

An Extended HPI for an inpatient renal consult

CC: Consult for acute renal failure

HPI: Patient is a 67 year old male with type 2 DM and hypertension, both of which had been fairly well controlled prior to admission.  He was admitted with acute CHF three days ago, which has improved with intravenous diuretic therapy.  Renal consult is called for elevated BUN and creatinine.

Coding Tip: If you use the 1997 E/M guidelines, a detailed HPI may be completed by using EITHER the HPI elements OR the status of three chronic or inactive problems.  Unfortunately, the 1995 E/M guidelines do NOT allow this flexibility.  This means that in clinical situations where there is no spontaneous somatic complaint from the patient which can be further described using the HPI elements, the physician MUST use the 1997 E/M guidelines to complete an extended HPI.

Coding Tip: Every type of encounter requires some form of HPI—not just initial visits, consults, and H&Ps.  If you are documenting a follow-up encounter (such as an office visit or a hospital progress note), it is acceptable to label the HPI an Interval History.

Coding Tip: The physician MUST personally complete and record the HPI.  The HPI is the ONLY part of the history which CANNOT be recorded by ancillary staff.