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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:
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.
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.
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:
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.
Use the acronym SOCRATES to ensure you’re able to document a complete and organized narrative:
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).
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.
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.
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.
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
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
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:
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.
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.
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.
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.