Medical record - History of Present illness and chief complaint

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

DG: The medical record should clearly reflect the chief complaint.


HISTORY OF PRESENT ILLNESS (HPI)

The 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. It includes the following elements:

location;

quality;

severity;

duration;

timing;

context;

modifying factors; and

associated signs and symptoms.


Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

DG: The medical record should describe one to three elements of the present illness (HPI).

An extended HPI consists of four or more elements of the HPI.

DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.