E & M Basic - history of illness

History of Present Illness

HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

** Location (example: left leg);

** Quality (example: aching, burning, radiating pain);

** Severity (example: 10 on a scale of 1 to 10);

** Duration (example: started three days ago);

** Timing (example: constant or comes and goes);

** Context (example: lifted large object at work);

** Modifying factors (example: better when heat is applied); and

** Associated signs and symptoms (example: numbness in toes).

There are two types of HPIs: brief and extended.

A brief HPI includes documentation of one to three HPI elements.

In the following example, three HPI elements – location, quality, and duration – are documented:

** CC: Patient complains of earache.

** Brief HPI: Dull ache in left ear over the past 24 hours.

An extended HPI:

** 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities.

** 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.


In the following example, five HPI elements – location, quality, duration, context, and modifying factors – are documented:

** CC: Patient complains of earache.

** Extended HPI: Patient complains of dull ache in left ear over the past 24 hours.

Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.