Why HPI Matters
Studies estimate that 80% of medical conditions can be correctly diagnosed through a thorough history of present illness alone. The HPI guides your differential diagnosis, treatment plan, and supports proper E/M coding for reimbursement.
What is HPI in Medical Terms?
HPI stands for History of Present Illness. It is a chronological, narrative description of the patient's current health complaint, documented from the onset of the first symptom to the present.
The HPI is written in full-sentence format by the clinician and serves as the foundation for clinical decision-making. It shapes your assessment and plan, guides your physical examination focus, and is essential for proper E/M coding and billing.
HPI vs. Chief Complaint
The Chief Complaint (CC) is a brief statement of why the patient is seeking care (e.g., "chest pain"). The HPI expands on this with detailed characterization of the symptom using the 8 elements.
HPI vs. PMH
The Past Medical History (PMH) documents previous conditions and treatments. The HPI focuses only on the current complaint and its evolution over time.
The OLDCARTS Mnemonic
OLDCARTS is the most widely used mnemonic for documenting a complete History of Present Illness. It helps ensure you capture all relevant information systematically.
The 8 HPI Elements
CMS defines 8 elements that can be documented in the HPI. For E/M coding purposes, a brief HPI includes 1-3 elements, while an extended HPI includes 4 or more elements.
Location
Where is the symptom located? Does it occur in one area or multiple areas?
- • Where exactly do you feel it?
- • Is it in one spot or does it move?
Quality
What is the character or nature of the symptom?
- • How would you describe it?
- • What does it feel like?
Severity
How intense is the symptom on a scale of 1-10?
- • On a scale of 1-10, how bad is it?
- • How does it compare to your worst pain ever?
Duration
How long has the symptom been present?
- • When did this first start?
- • How long does each episode last?
Timing
Is the symptom constant or intermittent? When does it occur?
- • Is it always there or does it come and go?
- • Is there a pattern?
Context
What circumstances or activities are associated with the symptom?
- • What were you doing when it started?
- • What triggers it?
Modifying Factors
What makes the symptom better or worse?
- • What makes it better?
- • What makes it worse?
Associated Signs/Symptoms
What other symptoms accompany the chief complaint?
- • Have you noticed anything else?
- • Any other symptoms?
HPI and E/M Coding Requirements
The number of HPI elements documented affects your E/M code selection. Here's what you need to know:
| HPI Level | Elements Required | Supports E/M Codes |
|---|---|---|
| Brief HPI | 1-3 elements | 99212, 99213 (lower complexity) |
| Extended HPI | 4+ elements | 99214, 99215 (higher complexity) |
| Extended HPI (Alternative) | 3+ chronic conditions | 99214, 99215 (status of chronic diseases) |
2025 Note: Since 2021, Medical Decision-Making (MDM) is the primary criterion for E/M code selection. However, documenting a complete HPI still supports your MDM complexity and is essential for clinical accuracy and audit defense.
The 4-2-1 Rule
Remember 4-2-1 for a Comprehensive history: 4 HPI elements + 2 PFSH sections + 1 item per ROS system reviewed.
HPI Examples by Specialty
CC: Chest pain for 2 days
The patient is a 55-year-old male presenting with substernal chest pain (Location) that started 2 days ago (Onset) after climbing stairs (Context). The pain is described as a pressure sensation (Quality) rated 6/10 (Severity). It lasts approximately 5-10 minutes per episode (Duration) and occurs with exertion (Timing). Rest and sitting down provide relief (Alleviating factors), while physical activity worsens symptoms (Aggravating factors). The patient denies radiation to the arm or jaw but reports associated shortness of breath and diaphoresis (Associated symptoms).
CC: Depressed mood for 3 weeks
The patient is a 32-year-old female presenting with low mood (Quality) that began approximately 3 weeks ago (Onset/Duration) following a job loss (Context). Symptoms are described as a persistent feeling of sadness and hopelessness (Quality) rated 7/10 in severity (Severity). The depression is constant throughout the day but worse in the mornings (Timing). Nothing seems to help (Modifying factors). Associated symptoms include insomnia, decreased appetite, fatigue, poor concentration, and passive suicidal ideation without plan or intent (Associated symptoms).
CC: Right knee pain for 1 week
The patient is a 45-year-old male runner presenting with right knee pain (Location) that began 1 week ago (Onset) during a marathon training run (Context). The pain is described as a sharp, catching sensation (Quality) on the medial aspect of the knee. Pain is rated 5/10 at rest, 8/10 with activity (Severity). Symptoms are intermittent, occurring with weight-bearing and stair climbing (Timing). Ice and NSAIDs provide partial relief (Alleviating factors), while running and squatting worsen pain (Aggravating factors). Associated symptoms include mild swelling and occasional knee locking (Associated symptoms).
Free HPI Template
Use this template structure to ensure complete HPI documentation:
HISTORY OF PRESENT ILLNESS: [Patient Name] is a [age]-year-old [gender] presenting with [chief complaint]. ONSET: Symptoms began [timeframe] [suddenly/gradually]. LOCATION: [Describe anatomical location(s)]. DURATION: Symptoms have been present for [timeframe] and each episode lasts [duration]. CHARACTER: Patient describes symptoms as [quality/nature]. AGGRAVATING FACTORS: Symptoms worsen with [triggers]. RELIEVING FACTORS: Symptoms improve with [alleviating factors]. TIMING: Symptoms are [constant/intermittent], occurring [pattern/frequency]. SEVERITY: Patient rates symptoms as [X]/10 at worst, [Y]/10 at baseline. ASSOCIATED SYMPTOMS: [List related symptoms or "denies any associated symptoms"]. PERTINENT NEGATIVES: Patient denies [relevant negative findings]. PRIOR TREATMENT: Patient has tried [previous treatments] with [results].
HPI Documentation Tips
Use systematic questioning
Follow OLDCARTS order to ensure you cover all elements consistently
Document in the patient's words
Use quotation marks for direct patient statements when appropriate
Include pertinent negatives
Document relevant symptoms the patient denies (supports differential)
Note prior treatments
Document what the patient has already tried and the results
Be specific with timing
Use exact dates/times rather than vague terms like "a while ago"
Avoid excessive detail
Focus on clinically relevant information that guides diagnosis
Frequently Asked Questions
What is HPI in medical terms?
HPI stands for History of Present Illness. It is a chronological description of the patient's current health complaint, from the first symptom to the present. The HPI is a critical part of medical documentation that guides diagnosis, treatment decisions, and supports proper E/M coding.
What are the 8 elements of HPI?
The 8 HPI elements are: (1) Location - where symptoms occur, (2) Quality - character of symptoms, (3) Severity - intensity on 1-10 scale, (4) Duration - how long symptoms persist, (5) Timing - constant vs intermittent, (6) Context - circumstances when symptoms occur, (7) Modifying factors - what makes it better/worse, (8) Associated signs/symptoms - related findings.
What is the OLDCARTS mnemonic?
OLDCARTS is a mnemonic for documenting the History of Present Illness: O=Onset (when did it start), L=Location (where is it), D=Duration (how long), C=Character (what does it feel like), A=Aggravating/Alleviating factors, R=Radiation (does it spread), T=Timing (constant or intermittent), S=Severity (1-10 scale).
What is the difference between brief and extended HPI?
A brief HPI documents 1-3 elements and supports E/M codes 99212-99213. An extended HPI documents 4 or more elements (or the status of 3+ chronic conditions) and is required for higher-level codes like 99214-99215. Extended HPI supports more complex medical decision-making.
How many HPI elements are needed for 99214?
You must document 4 or more HPI elements to qualify for 99214. This constitutes an extended HPI. Alternatively, you can document the status of at least 3 chronic or inactive conditions. Remember that as of 2021, medical decision-making (MDM) is the primary criterion for E/M code selection.
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