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HPI Writeup Templates
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Basic - One chief complaint
Opening statement: Chief complaint in light of the patient’s clinical context
Elaborate description of the chief complaint
Accompanying symptomatology
Absent pertinent symptomatology
Pertinent PMHx, Family Hx, Social Hx
Concluding statement: How the patient got to the care site
CC with one other prominent secondary symptom
Opening statement: Chief complaint in light of the patient’s clinical context
Elaborate description of the chief complaint
Prominent accompanying symptom
Elaborate description of the other prominent symptom
Accompanying symptomatology
Absent pertinent symptomatology
Pertinent PMHx, Family Hx, Social Hx
Concluding statement: How the patient got to the care site
CC which is likely a symptom of an exacerbation of chronic illness
Opening statement: Chief complaint in light of the patient’s clinical context
Elaborate description of the chief complaint.
Description of condition and symptom control of the chronic illness (Diagnosis or symptom, When diagnosed, Complications, Treatments, Recent symptom control prior to this exacerbation)
Accompanying symptomatology
Absent pertinent symptomatology
Pertinent PMHx, Family Hx, Social Hx
Concluding statement: How the patient got to the care site
Hospitalized patient - Initial CC, Hospital course & New CC
Opening statement: Chief complaint in light of the patient’s clinical context
Elaborate description of the chief complaint
Prominent accompanying symptom
Elaborate description of the other prominent symptom
Accompanying symptomatology
Absent pertinent symptomatology
Pertinent PMHx, Family Hx, Social Hx
Concluding statement: How the patient got to the care site
Additional sections for the hospitalized patient
Hospital course (since admission):
Working diagnosis
Definitive diagnostic work-up that led to the final diagnosis (e.g. imaging, procedures, biopsy)
Describe key therapeutic events (e.g. surgery)
Other critical events while in the hospital (e.g. fall, delirium)
At the time of interview:
Any new complaints/concern (follow HPI template if significant)
Further additional diagnostic or therapeutic events
If applicable, discharge plans
No Chief Complaint or Follow-Up Visit
Opening statement: Simple statement of the patient and medical problems
Status report of the patient’s chronic conditions/illnesses (Pertinent symptoms – present & absent, Current treatment and response, Prior relevant labs/studies)
Concluding statement: How the patient got to the care site