The first thing your patient note examiner will read is your HPI…
So it’s fair to say that the quality of your HPI can set the tone for how the rest of your note is perceived.
The HPI is your note’s introduction and is what gives the reader a look into the patient’s complaint. Here are a few tips that will help ensure that your HPI is as strong as possible:
Tip 1: Ensure that you include as much information as possible relating to the complaint… This ensures that the reader isn’t left asking questions or trying to fill in any blanks on their own. You want your reader to have complete understanding of the problem at hand.
Tip 2: Follow a logical sequence: This means that you should start by introducing the complaint by explaining the location, intensity, quality, etc. Then discussing whether it is constant/intermittent, the frequency, duration, etc. Then moving onto the aggravating & alleviating factors, then finishing with the associated signs and symptoms. The way you discuss the problem needs to be well structured and not jumbled.
Tip 3: Include pertinent negative finds at the end of the HPI: Some students tend to toss in negative findings too early in the HPI, when you should first explain what’s going on… Then to round out the HPI, explain some of the negative findings that can help to better understand the problem and rule out certain differentials.
These are just a few tips that if implemented immediately, will help to improve the overall quality of your HPI.
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