New Patient History Sheet Owensboro Health 2015-2026

Key elements of the history of present illness template

The history of present illness (HPI) template is essential for documenting a patient's current health status and the progression of their symptoms. Key components include:

• Chief complaint: A brief statement describing the primary issue that prompted the patient to seek care.
• Onset: When the symptoms began, which can help in determining the urgency and nature of the condition.
• Location: The specific area of the body affected by the symptoms, which aids in diagnosis.
• Duration: How long the symptoms have been present, providing insight into the condition's progression.
• Characteristics: A description of the symptoms, including their nature, intensity, and any associated factors.
• Aggravating and relieving factors: What makes the symptoms worse or better, which can guide treatment options.
• Associated symptoms: Any other symptoms that occur alongside the primary complaint, offering a fuller picture of the patient's health.

Steps to complete the history of present illness template

Completing the history of present illness template involves a systematic approach to gathering information. Follow these steps:

1. Gather patient information: Start with the patient's demographic details, including name, age, and contact information.
2. Document the chief complaint: Clearly note the primary reason for the visit, using the patient's own words when possible.
3. Ask detailed questions: Use the HPI questions to explore the onset, duration, and characteristics of the symptoms.
4. Record the patient's responses: Write down the answers accurately, ensuring clarity and completeness.
5. Review the information: Ensure all relevant details are captured and check for any missing elements.
6. Finalize the document: Prepare the template for review by healthcare providers, ensuring it is clear and professional.

Examples of using the history of present illness template

Utilizing a history of present illness template can enhance patient care through structured documentation. Here are some examples:

• A patient presents with chest pain. The HPI template captures the onset, duration, and characteristics, leading to a timely diagnosis.
• For a patient with chronic headaches, the template helps track patterns and triggers, providing valuable data for treatment adjustments.
• In cases of acute illness, such as a respiratory infection, the template documents symptom progression, aiding in effective management.

Legal use of the history of present illness template

The history of present illness template must be used in compliance with legal and regulatory standards. Key considerations include:

• Confidentiality: Ensure that patient information is kept private and secure, adhering to HIPAA regulations.
• Accuracy: Document information accurately to avoid legal issues related to misdiagnosis or inadequate care.
• Retention: Maintain records for the required duration as mandated by state laws and healthcare regulations.

How to obtain the history of present illness template

Obtaining a history of present illness template can be straightforward. Options include:

• Healthcare institutions: Many hospitals and clinics provide standardized templates to their staff.
• Online resources: Various medical websites offer downloadable templates that can be customized for specific needs.
• Professional organizations: Associations in the healthcare field often provide resources, including templates, for their members.

Present illness example

An example of a well-documented history of present illness might include:

A 45-year-old male presents with a three-day history of worsening chest pain. The pain began suddenly while at rest, is sharp in nature, and radiates to the left arm. The patient reports associated symptoms of shortness of breath and nausea. Pain is aggravated by deep breathing and relieved by sitting upright. No prior history of similar symptoms.