In a medical encounter, a history of the present illness (HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Questions to include
Different sources include different questions to be asked while conducting a HPI, but in general they include the following:
- onset
- location and radiation
- severity and character/quality
- duration and timing
- precipitating and palliating factors
- progression
Acronyms
Several acronyms have been developed to categorize the appropriate questions to include:
- "OPQRST". [1][2] Alternatively, "PQRST". [3][4] See also Opqrst.
- "CLEARAST" [5]
- "LIQOR AAA" [6]
- "FAR COLDER"
- "OLD CART"
Medicare definitions
The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of the following elements:
- location
- quality
- severity
- duration
- timing
- context
- modifying factors
- associated signs & symptoms
A "extended HPI" includes four or more of these elements. [7] [8]
See also
- medical record
- medical history
- pain scale
References
- Adler H. "The history of the present illness as treatment: who's listening, and why does it matter?". J Am Board Fam Pract. 10 (1): 28–35. PMID 9018660.
Footnotes
- ↑http://hopperinstitute.com/emt_medical.html
- ↑http://www.alpharubicon.com/med/medaccesshaumanao.htm
- ↑http://www.wemsi.org/pqrst.html
- ↑http://www.usask.ca/medicine/medicine/clsc.htm
- ↑http://dartmed.dartmouth.edu/spring06/html/student_notebook.php
- ↑http://www.aippg.net/forum/viewtopic.php?p=71106
- ↑http://www.emrconsultant.com/emr_EMcoding.php
- ↑http://www.usc.edu/health/uscp/compliance/tm6.html#6
External links
- Overview at usc.edu
- Overview at medicine.ucsd.edu
- Overview at nur.utexas.edu
- Template:LoyolaMedEd
- Overview at medinfo.ufl.edu
