How to hack the HPI into a checklist (Part 3 of 4)

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If you missed parts 1 or 2 of this 4 week HPI breakdown, check them out here.

As I said in week 1, the taking of a good history can be both a diagnostic and a therapeutic tool. Then, the process of writing your HPI is just as important as the HPI itself.

Many medical errors are not due to diagnostic dilemmas, they’re from failing to do the basics. Failing to do the basics happens when you’re not organized. Systems help you stay organized and ensure consistency. By writing your HPI the same way every time using my tips below, you create systematic built in checklists. Let's look back at 2 of my previous suggestions:

1. No more than 3 - 4 medical conditions pertinent to the chief complaint

A nocturnist admitted a patient to my service where he copy and pasted a problem list into the HPI that included FIFTEEN medical conditions. The patient had presented with shortness of breath and a unilateral pleural effusion. He treated the patient for heart failure. The problem?

It wasn’t heart failure. A review of the problem list would have given a hint of the ultimate diagnosis: Active lung cancer.

Admissions can be overwhelming, especially with extensive medical histories. But if he used the opportunity while writing his HPI to REVIEW the problem list and pick out only 3 - 4 that were pertinent to shortness of breath and a pleural effusion (instead of just copy and pasting them) the active lung cancer likely would have been higher on his differential.

He did mention the lung cancer in his A&P, which could have been another chance to reconsider his treatment, but it seems he had already anchored onto heart failure.

Don’t think he’s just a bad doctor. This can happen to you when you’re in a rush. When you’re stressed, most think they’ll “rise to the occasion.” However, most sink to the level of their systems and training. Systems and habits keep you consistent and complete even when you ARE in a rush. Remember, failure to do the basics is the most dangerous.

Let’s look at my next tip:

2. Details in parenthesis

Include important details about a condition that most clinicians would want to know when treating that patient in paranethesis after listing that condition in the first sentence of the HPI. These may include supplemental O2 requirements for chronic lung conditions, blood thinners or ejection fraction for heart failure to name a few. Don’t get too crazy with it, though. Remember to be concise.

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

I’ve lost track of the number of patients admitted to me who had their anticoagulation continued in the midst of a GI bleed. Or bolused with fluids despite a severely reduced LVEF. When brought up to the physicians, it was clear they KNEW those obvious basics, but their lack of a systematic workflow caused them to make an error.

The (details) become their own checklist before you move forward. When you write “eliquis” and “bright red blood per rectum” in the same sentence, you’re far less likely to accidentally continue that medication. It’s staring you in the face. The same with the other examples.

When you’re in the habit of listing the (details) after conditions, you’ll get in the habit of CHECKING these details before seeing the patient so you can clarify them with the patient. It’s not fun to finish your history and physical, walk back to your computer, start writing your note and realize you should have asked about certain things. That’s frustrating and inefficient…and I can almost guarantee you most don’t go back and ask. So, ensuring it all on the front end by habitual systems ensures quality and improves patient care.

By the way, did you notice I used only “with” rather than, “with a past medical history of” in the example?

That’s on purpose. That’ll be my next issue… See you then!

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

Cheers,

Robert

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