Menu Close

How to Document History of Present Illness?

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. 

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.

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 medical billing experts who offer comprehensive billing and coding services to doctors, physicians & hospitals. We provide end to end billing and coding solutions. Medisys Data Solutions RCM solutions ensures that the providers recover every $ they are entitled to. Our vision for the providers is “You Cure. We $ecure.”

Related Posts

Leave a Reply

Your email address will not be published. Required fields are marked *