HPI Meaning in Medical Terms: History of Present Illness Explained
Complete guide to HPI (History of Present Illness) documentation including the 8 elements, OLDCARTS mnemonic, examples, and E&M coding requirements for 2026.
Table of Contents
What is HPI in Medical Terms?
HPI stands for History of Present Illness. It is a critical component of the medical history that provides a chronological description of the patient's current symptoms or chief complaint from onset to the present encounter.
The HPI tells the "story" of the patient's illness from their perspective. It documents how symptoms developed, what makes them better or worse, and any associated symptoms. This narrative helps clinicians understand the progression of the illness and guides diagnosis and treatment decisions.
Definition
"The 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 to the present."
— CMS Documentation Guidelines
Where Does HPI Fit in Medical Documentation?
In SOAP notes and traditional medical documentation, the HPI is part of the "Subjective" section because it contains information provided by the patient (or their representative), not objective clinical findings.
S - Subjective
Chief Complaint, HPI, ROS, PFSH
O - Objective
Physical Exam, Vitals, Labs
A - Assessment
Diagnosis, Clinical Impression
P - Plan
Treatment, Follow-up
The 8 Elements of HPI
According to CMS documentation guidelines, there are 8 recognized elements of the History of Present Illness. Including more elements creates a more complete picture of the patient's condition.
Location
Where on the body the symptom or problem occurs
Examples: "Lower back pain," "right knee swelling," "substernal chest pain"
Quality
Characteristics of the symptom - how it looks or feels
Examples: "Sharp pain," "dull ache," "throbbing," "burning sensation"
Severity
How bad the symptom is, often on a 1-10 scale
Examples: "6 out of 10 pain," "unbearable," "mild discomfort"
Duration
How long the symptom has been present
Examples: "Started 3 days ago," "present for 2 weeks," "chronic for 6 months"
Timing
When symptoms occur and their pattern
Examples: "Constant," "intermittent," "worse at night," "occurs after meals"
Context
Circumstances or activities surrounding symptom onset
Examples: "Started while exercising," "after lifting heavy box," "during stress"
Modifying Factors
What makes the symptom better or worse
Examples: "Improves with rest," "worsens with movement," "OTC meds not helping"
Associated Signs/Symptoms
Other symptoms occurring with the chief complaint
Examples: "Nausea and sweating with chest pain," "fever with cough"
OLDCARTS Mnemonic for HPI Documentation
OLDCARTS is a popular mnemonic used by medical students, nurses, and physicians to remember the key elements to include when documenting the History of Present Illness. It ensures comprehensive symptom documentation.
When did the symptoms start? Was it sudden or gradual?
Where are the symptoms located? Does it radiate?
How long have the symptoms been present?
What is the nature/quality of the symptom?
What makes the symptoms worse?
What alleviates the symptoms?
Are symptoms constant or intermittent?
How severe are the symptoms on a 1-10 scale?
Alternative Mnemonics
- SOCRATES - Site, Onset, Character, Radiation, Associations, Time course, Exacerbating factors, Severity
- PQRST - Provocation/Palliation, Quality, Region/Radiation, Severity, Timing
- OPQRST - Onset, Provocation, Quality, Region/Radiation, Severity, Time
Chief Complaint vs HPI: What's the Difference?
Chief Complaint (CC)
- Brief statement of why the patient is seeking care
- Usually stated in the patient's own words
- Short and concise (1-2 words or brief phrase)
- Examples: "chest pain," "cough," "fatigue"
History of Present Illness (HPI)
- Detailed expansion of the chief complaint
- Chronological narrative of symptom development
- Includes multiple elements (location, severity, duration, etc.)
- Comprehensive paragraph or detailed bullets
Example Comparison
HPI Examples by Specialty
Primary Care: Hypertension Follow-up
CC: Follow-up for high blood pressure
HPI: 58-year-old male with history of hypertension presents for routine follow-up. Patient reports good medication compliance with lisinopril 10mg daily. He denies headaches, visual changes, chest pain, or shortness of breath. Home blood pressure readings have been averaging 135/85mmHg over the past month. Patient notes mild ankle swelling in the evenings that resolves overnight. He has been maintaining a low-sodium diet but admits limited exercise due to knee arthritis. No symptoms of dizziness or orthostatic hypotension.
Emergency Medicine: Chest Pain
CC: Chest pain
HPI: 62-year-old male with history of hyperlipidemia and smoking presents with substernal chest pain (location) that started 1 hour ago (onset) while mowing the lawn (context). The pain is described as "pressure-like" (quality), rated 8/10 (severity), constant since onset (timing), radiating to the left arm. Associated symptoms include diaphoresis and nausea. Pain is not relieved by rest or antacids. Patient took aspirin 325mg prior to arrival. He denies shortness of breath, palpitations, or recent illness. Last meal was 4 hours ago.
Psychiatry: Depression Follow-up
CC: Follow-up for depression
HPI: 34-year-old female presents for 6-week follow-up since starting sertraline 50mg. Patient reports gradual improvement in mood over the past 3 weeks. She notes better sleep quality, sleeping 7 hours nightly compared to 4-5 hours previously. Energy levels are "somewhat better" but still not at baseline. Patient reports decreased frequency of crying spells (from daily to 1-2 times weekly). Appetite has normalized. She denies suicidal ideation, self-harm thoughts, or auditory/visual hallucinations. Side effects include mild nausea for the first week that has since resolved. Patient has been attending weekly therapy sessions.
Orthopedics: Knee Pain
CC: Right knee pain
HPI: 52-year-old male presents with right knee pain (location) that has been progressively worsening over the past 6 months (duration). The pain is described as a deep ache (quality), rated 5/10 at rest and 8/10 with activity (severity). Pain is worse in the morning with stiffness lasting about 30 minutes (timing). Climbing stairs and prolonged walking aggravate symptoms (aggravating factors), while rest and ice provide some relief (modifying factors). Patient notes occasional "grinding" sensation and intermittent swelling (associated symptoms). No history of trauma. He has tried OTC NSAIDs with moderate benefit. Patient is a former marathon runner.
HPI Documentation Requirements
Brief HPI
Requires 1-3 HPI elements
- • Appropriate for straightforward visits
- • Supports lower E/M levels (99212-99213)
- • Common for simple acute complaints
Extended HPI
Requires 4 or more HPI elements
- • Supports higher E/M levels (99214-99215)
- • Required for comprehensive histories
- • Standard for complex visits
Important Documentation Notes
- • Under older CMS guidelines, only the billing physician could document the HPI
- • Since 2021 E/M changes, ancillary staff documentation is now acceptable for office visits
- • The HPI should always be based on patient interviews, not assumptions
- • Document pertinent negatives (what the patient denies)
- • Be specific with timing - "a few days" should be "3 days"
HPI and E&M Coding for 2026
The role of HPI in E&M coding has evolved significantly. Under the 2021 CMS changes (extended to other E&M services in 2023), medical decision-making (MDM) or total time are now the primary determinants for selecting E/M levels for most services.
Key 2026 E/M Considerations
Office/Outpatient Visits (99202-99215)
HPI documentation is still required but doesn't directly determine code level. Focus on MDM or time.
Hospital and ED Services
Similar MDM-based selection now applies. HPI supports clinical reasoning but isn't counted for level selection.
Medical Necessity
A thorough HPI still supports medical necessity and clinical decision-making documentation.
The "4-2-1" Rule (Historical Reference)
For services still using 1995/1997 guidelines, the "4-2-1" rule ensured a comprehensive history:
- • 4 HPI elements (extended HPI)
- • 2 areas of PFSH (past/family/social history)
- • 1 item per system for ROS (at least 10 systems)
Best Practices for HPI Documentation
Be Specific with Timing
Instead of "a while ago," document "3 weeks ago" or "since Monday."
Use Patient's Words
Quote the patient when describing quality: "feels like an elephant on my chest."
Document Pertinent Negatives
"Denies fever, nausea, or vomiting" helps narrow the differential diagnosis.
Follow Logical Order
Start with onset, then describe progression chronologically to the present.
Quantify When Possible
Use scales (1-10 for pain), frequencies, and measurable units.
Include Prior Treatments
Document what the patient has already tried and the results of those treatments.
Connect to Chief Complaint
Every HPI element should relate back to why the patient is seeking care.
Avoid Copy-Forward Errors
Ensure each HPI reflects the current visit, not outdated information from previous encounters.
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Start Free TrialFrequently Asked Questions
What does HPI stand for in medical terms?
HPI stands for History of Present Illness. It is a detailed chronological description of the patient's current symptoms or chief complaint, documented as part of the medical history during a clinical encounter.
What are the 8 elements of HPI?
The 8 elements of HPI are: Location (where the symptom occurs), Quality (characteristics of the symptom), Severity (how bad it is), Duration (how long it has lasted), Timing (when symptoms occur), Context (circumstances surrounding onset), Modifying Factors (what makes it better or worse), and Associated Signs and Symptoms.
What is the difference between chief complaint and HPI?
The chief complaint (CC) is a brief statement of why the patient is seeking care, usually in the patient's own words (e.g., "chest pain"). The HPI expands on the chief complaint with a detailed chronological description of the symptom's onset, duration, severity, and other relevant factors.
What is the OLDCARTS mnemonic for HPI?
OLDCARTS is a mnemonic for documenting HPI: Onset (when symptoms started), Location (where symptoms occur), Duration (how long), Character (what it feels like), Aggravating factors (what makes it worse), Relieving factors (what helps), Timing (constant or intermittent), and Severity (1-10 scale).
How does HPI affect E&M coding and billing?
Under the 1995/1997 CMS guidelines, a Brief HPI (1-3 elements) supports lower E/M levels, while an Extended HPI (4+ elements) supports higher levels. However, since 2021 for office visits, medical decision-making (MDM) is the primary determinant for E/M level selection, reducing HPI's direct billing impact.