How to Write an HPI (History of Present Illness)

The history of present illness (HPI) is the part of a clinical note that tells the story of the patient's current problem, from the first symptom to the present. To write a strong HPI, describe the problem in a clear chronological narrative and cover the key descriptors: what it is, where it is, how severe, when it started, what makes it better or worse, and what came with it. A good HPI sets up the entire assessment, because it is where the clinical reasoning begins.

What Is the History of Present Illness?

The HPI is a chronological description of the development of the patient's illness from the first sign or symptom to the current presentation. It is the core of the subjective history and the foundation of the note: the assessment and plan should follow logically from what the HPI describes. StatPearls, on the NCBI Bookshelf, describes the HPI as usually encompassing eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms (see Medical History).

The HPI appears in most note types. It is the S in a SOAP note, a central part of an H&P note, and the anchor of a focused progress note.

The Elements of a Complete HPI

The eight descriptors give a reliable checklist for capturing a problem fully. Not every element applies to every complaint, but running through them prevents gaps.

OLDCARTS and OPQRST

Two mnemonics cover the same ground and help clinicians remember the elements at the bedside. OLDCARTS stands for Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity. OPQRST stands for Onset, Provocation/palliation, Quality, Region/radiation, Severity, and Timing. Either framework produces a complete HPI; the choice is personal preference.

How to Write an HPI Step by Step

1. Start with a clear opening line: identify the patient, the relevant background in a phrase, and the chief complaint with its duration (for example, the reason for the visit and how long it has been going on).
2. Tell the story in order: describe how the problem began and evolved, chronologically, rather than listing findings out of sequence.
3. Work through the descriptors: cover the relevant elements from OLDCARTS or OPQRST so the picture is complete.
4. Include pertinent positives and negatives: note the related symptoms that are present and the important ones that are absent, since both shape the differential.
5. Add relevant context: prior episodes, related treatments already tried, and anything that changes the interpretation.
6. End where the assessment begins: the HPI should give the reader enough to understand the reasoning that follows.

HPI Example

The example below is short and generic, written for illustration only. It does not describe a real patient.

The patient reports a three-day history of a productive cough with yellow sputum, associated with a fever to 38.6 C and mild shortness of breath on exertion. The cough is worse at night and partially relieved by rest. There is no chest pain, no hemoptysis, and no recent travel. Symptoms began after a week of upper respiratory congestion. No prior episodes of pneumonia.

In a few sentences, this covers onset, duration, quality, associated symptoms, modifying factors, and pertinent negatives, which is what a complete HPI does.

The HPI and E/M Coding: An Important Update

For years, the number of HPI elements documented helped determine the level of a history for evaluation and management coding. That changed for office and outpatient visits. Under the current E/M framework, office/outpatient visit levels (99202 to 99215) are selected by medical decision making or total time, not by counting history and exam elements. The clinician still must document a medically appropriate history, and the HPI remains clinically essential, but it is no longer scored to pick the code level for these visits. For how leveling works now, see this guide to E/M coding and documentation.

Common HPI Mistakes to Avoid

• Listing symptoms without a chronological narrative, so the story is hard to follow.
• Omitting pertinent negatives that would narrow the differential.
• Copying a prior HPI forward without updating it for today's visit.
• Being vague about severity, timing, or duration, which are the details that guide the assessment.

How an AI Scribe Helps With the HPI

The HPI is spoken during the visit as the patient tells their story, which makes it a natural fit for ambient documentation. DocuMed AI is a HIPAA-compliant AI medical scribe that captures the conversation on a mobile device, tablet, or web app, encrypts the audio the instant it is captured, and drafts a note on HIPAA-compliant servers, including an HPI built from what the patient actually described.

Because the clinician is listening and asking questions rather than typing, the HPI can be more complete and chronological. The clinician then reviews, edits, and finalizes the draft, correcting anything the AI misheard, before copying it into the EHR. The clinician remains the author of the note. To see the workflow, visit How It Works.

Frequently Asked Questions

What are the elements of the HPI?

The HPI usually covers eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs or symptoms. The mnemonics OLDCARTS and OPQRST are common ways to remember them.

What is the difference between OLDCARTS and OPQRST?

Both are mnemonics for capturing the same descriptors of a symptom. OLDCARTS emphasizes onset, location, duration, character, and aggravating and relieving factors; OPQRST emphasizes provocation, quality, region and radiation, severity, and timing. Either produces a complete HPI.

Does the HPI still affect E/M coding?

For office and outpatient visits, no: those levels are now selected by medical decision making or total time, not by counting history elements. The clinician still documents a medically appropriate history, and the HPI remains clinically important.

Can an AI scribe write the HPI?

An AI scribe can draft an HPI from the recorded conversation, capturing the chronology and key descriptors. The clinician then reviews and edits it for accuracy before finalizing the note.