The 5 steps to telling the HPI Story

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If you haven’t already, read last week’s issue before continuing:

Remember in that email I said there are three uses of the HPI:

1. To tell the patient’s story

2. To communicate with the care team

3. To act as a quality-assurance tool

Last week’s issue was about #1. This week is about #2.

Once you’ve obtained the story, you want to succinctly and accurately communicate it to the rest of the care team in a way that is clinically helpful. There are 5 steps to do this well:

1. Tell the chief complaint as soon as possible.

2. List pertinent positives and negatives after introducing new information.

3. List no more than 3 - 4 pertinent medical conditions with details listed in parenthesis in the first sentence.

4. Tell a chronological story.

5. Keep it readable.

Let’s dig in.

1. Tell the chief complaint as soon as possible.

Read that again.

Chief complaints buried several lines down in a wall of text have become such an issue that I now check the ER nurse triage note (which typically includes the chief complaint in the patient’s words) before reading an HPI. The chief complaint frames the rest of the HPI.

Anyone who has taken standardized testing has been told to “read the question first” and THEN go back and read the prompt. Knowing the chief complaint is “reading the question first.” If someone presented with shortness of breath, then the rest of the HPI should answer the question, “Why are they short of breath?” Which leads to my next point…

2. List pertinent positives and negatives after introducing new information.

Before walking into a patient’s room to take a history, you should have a differential list in your head. Your history-taking should eliminate some and make others more likely. This should be standard for any physician / APP.

However, many lose this aspect in their HPI. Your HPI should be no different. A well-written HPI knows which questions readers are asking themselves while reading your HPI. If a diagnosis was clear by the time you were done with your history-taking, the same should go for your HPI.

My pet peeve is the long list of “review of system” type questions listed at the end of the HPI paragraph. If they were pertinent to something, they’ve lost their pertinence at the end of the paragraph. Most people’s brains shut off when they see this long list and skip it.

Example: “Patient had coffee ground emesis. She does not drink alcohol. She takes 600mg ibuprofen three times a day for osteoarthritis.”

New information: Coffee ground emesis.

Pertinent Negative: She does not drink alcohol.

Pertinent Positive: NSAID use.

You are convincing your reader she is at risk for NSAID induced peptic ulcer disease and your recommendation for PPI and EGD will be clear.

Oh, and the Review of Systems is no longer required for billing - so don’t list it at the end for that reason either.

2. List no more than 3 - 4 pertinent medical conditions with details listed in parentheses in the first sentence.

After knowing the chief complaint, medical conditions which are already known should be listed. This narrows the differential for your readers and gives additional context to the chief complaint.

For the sake of communication, why list no more than 3 - 4 medical conditions? Most humans do not have the running memory to keep more than that in their heads while reading the rest of your HPI. (This will also help you as a quality assurance tool…more on that next week.)

Additionally, certain medical conditions have major factors that every clinician will want to know. Examples include the LVEF of heart failure and anticoagulation for atrial fibrillation. Certain details may rise to importance given the chief complaint. Is a patient coming in with a GI bleed? Any conditions with blood thinner implications are important.

Example: “68-year-old male presents with bright red blood per rectum x 3 days with CAD (not on asa/plavix), atrial fibrillation (eliquis), and HFrEF (LVEF 35%).”

That first sentence gives you a LOT of context. Eliquis is likely contributing to the bleed. Thank goodness they’re not on asa/plavix as well. The reduced EF is front and center - so, it’s not going to be lost in the mix and hopefully this patient is not given too much fluid or blood too fast (I’ve seen too many patients develop pulmonary edema in such a situation only to discover they have systolic heart failure but it wasn’t documented anywhere and therefore no one knew about it).

Another example: “68-year-old male presents with right sided weakness and slurred speech. He has CAD (on asa/plavix), atrial fibrillation (eliquis), HTN and IDMII (A1c 11%).

Wow, he’s on triple therapy and appears to be having a stroke?! Your HPI should include further information that should suggest why he’s having a stroke despite this. Incomplete compliance with medications? Other poorly controlled reversible risk factors such as diabetes or smoking? Or…is it a hemorrhagic stroke? Which leads me back to my tip from last week:

4. “Tell a chronological story from the time things changed up until they came to you.” 

I won’t rehash the chronological points from last week. I’m a hospitalist, so I receive consults from the ER. That means they’ve already had a work-up and some treatment there - Include it! Yes…include the ER course in the HPI. We’re taught in med school and residency to not do this but it’s efficient, functional and largely standard practice in non-academic practice. Why?

We’re all busy. Your HPI should not be a mystery. Don’t make your readers go digging for answers. Your reader is trying to help you and your patient… so help them by giving them answers efficiently when they’re already available.

So, for the example above, I’d include the ER course that says, “CT head showed subarachnoid hemorrhage,” etc. Now any consultant that comes behind me and reads my HPI is up to date. But, here’s my last point:

5. Keep it readable.  

When you get to your ER course, start a new paragraph with a page break. Our eyes and brains really don’t like walls of text. They love white space. This keeps it readable. Also, and this is surprisingly a big enough issue that I must say this: use punctuation and standard sentence structure. One long continuous run on sentence does not help readability.

Humans have an innate curiosity for “What happens next?” We love stories. So, the ultimate “keep it readable” tip is telling a chronological story, step by step. (But, again, avoid the cliff hanger with the HPI defining “of note” at the end). This includes any preceding events, baseline status, etc that I mentioned in last week’s issue before getting to the chief complaint.

Succinctness is also key to readability. Delete unnecessary wordiness likely “patient reports” over and over and understand what is pertinent and what is not to keep the HPI concise.

Enough about the patient and other readers… how can you use the HPI to help YOU?! That’ll be in my next issue. See you then!

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That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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