DocScrib HPI Template with Practical Examples for Clinicians

History of Present Illness (HPI) Template with Examples for Clinicians

Crafting an effective History of Present Illness (HPI) is pivotal in clinical reasoning—it captures the essence of the patient’s current health issue in a structured narrative. A well-designed HPI template ensures consistency, improves diagnostic accuracy, saves time, and supports billing compliance. With DocScrib’s AI Medical Scribe, clinicians can enhance accuracy and document efficiently.

🔍 What Is an HPI?

The History of Present Illness is a detailed, chronological account of the patient’s chief complaint, tracing its onset, symptoms, modifiers, and impact. It’s a key part of the subjective assessment in a SOAP note and forms the backbone of effective clinical decision-making.

🛍️ Why Use an HPI Template?

• Consistency & Completeness: Ensures all key elements—onset, character, modifiers, severity, etc.—are captured.
• Diagnostic Accuracy: Up to 80% of diagnoses are achieved through an effective HPI.
• Time Efficiency: AI-enhanced documentation speeds up note-taking while maintaining quality.
• Billing Compliance: Aligns with CMS guidelines—brief HPI (1–3 elements) vs. extended HPI (≥4 elements).

🔧 Core Elements of a Robust HPI Template

A reliable HPI uses mnemonic tools like OLD CARTS or SOCRATES, covering these key components:

1. Onset – When did symptoms begin?
2. Location – Where is the symptom?
3. Duration – How long has it been present?
4. Characteristics – What does it feel like (e.g. sharp, burning)?
5. Aggravating/Alleviating factors – What worsens or relieves it?
6. Timing – Is it constant, intermittent, or episodic?
7. Severity – Intensity on a scale (e.g. 0–10)?
8. Associated symptoms – Are there related symptoms?

📋 Step-by-Step Guide with Example

Here’s how to convert these elements into a cohesive narrative:

• Chief Complaint: “4-day left-sided chest pain.”
• Onset: Sudden onset 4 days ago while climbing stairs.
• Location: Left mid-sternum.
• Duration: Lasts 10–15 minutes, comes and goes.
• Character: Pressure-like sensation, moderate intensity.
• Aggravating factors: Worse with exertion, especially stairs.
• Alleviating factors: Relieved by rest and nitroglycerin.
• Timing: Starts mid-morning, 2–3 times per day.
• Severity: “6/10.”
• Associated symptoms: Occasional shortness of breath, no diaphoresis or nausea.

Narrative HPI Example:
“Mr. Smith is a 58-year-old man presenting with a 4-day history of intermittent left mid-sternal pressure, onset during stair climbing. Episodes last 10–15 minutes and rate 6/10, worsen with exertion and improve with rest or nitroglycerin. He reports occasional shortness of breath but denies chest heaviness, diaphoresis, or nausea.”

🎥 HPI in Action: Video Walkthroughs

1. How to Write an HPI – Watch on YouTube
2. OLDCART Mnemonic Explained – Watch on YouTube
3. Medical History Interview Demo – Watch on YouTube

💡 Pro Tips for Capturing a Strong HPI

• Open-ended questions first (“Tell me more about your chest pain”) to avoid bias.
• Use direct quotes for clarity and context.
• Integrate system-level screening if symptoms suggest broader issues.
• Anchor the HPI with a concise narrative ending: age, complaint, timeline, severity.

🔄 Role of DocScrib in HPI Documentation

With DocScrib’s AI Scribe, you can:

1. Speak naturally during patient conversations—DocScrib captures OLD CARTS elements.
2. Auto-structure notes into your EHR-ready template.
3. Customize templates depending on visit type—emergency, chronic care, or wellness.
4. Save valuable time, allowing clinicians to focus on patients.

✅ Key Takeaways

• A thorough HPI is foundational to diagnosis and care planning.
• Templates using OLD CARTS or SOCRATES ensure essential details aren’t missed.
• Effective HPI documentation can be automated efficiently with AI tools like DocScrib.
• Practicing with structured templates enhances clarity and supports billing accuracy.

👉 Download your free, customizable HPI Template now and elevate your clinical documentation with DocScrib!