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I expected the usual shallow feedback with a blank comments box.

“Often misses important details in the history.”

I paused.

And read it again.

I was offended, disappointed, sad… But I eventually did come to a conclusion:

He was right.

And since that feedback over 8 years ago intern year, I’ve refined both my history-taking and HPI writing skills. CDI considerations and open-chart laws have provided additional optimization. What I’ve learned is that there are 3 purposes of an HPI:

1. To tell the patient’s story

2. To communicate with the clinical care team

3. To act as a quality-assurance tool

This was going to be a single issue, but I’ve decided to break it into four separate weekly issues.

Let’s dig in.

A patient’s story

He looked at his wife and then back at me. “Well, I did have a terrible sore throat about two weeks ago.”

I think I audibly gasped.

We’ll come back to him later…

HPI’s should not just be a list of details around a chief complaint. We are humans treating humans and as humans we relate to stories. They have a story we need to know, and we will understand how to treat them if we know their story. Stories elicit curiosity, compassion and connection.

We were a verbal species long before we developed written word. Folktales, traditions and religions were all passed down for millennia… in the form of stories (and song but… maybe don’t sing the HPI). It’s in our makeup.

My major HPI tip is this: Tell a chronological story from the time things changed up until they came to you. People gloss over that tip because it sounds obvious, but it’s often done wrong, and each part of that sentence is more important than you realize.

Stories have a beginning and an end and the chief complaint is typically somewhere in the middle. The chief complaint almost always exists within the context of other factors - other medical conditions, medications, social factors, preceding events, etc. These are often just as, and sometimes more, important than the chief complaint. Too often people jump straight to asking about qualifiers around a chief complaint and end there.

After telling me their chief complaint, I confirm exactly when it started and then try to start from the beginning. I ask some version of “When is the last time you felt normal?” or “has anything changed recently?” or specifically ask about the day before chief complaint onset

The Diagnostic Story

Back to our sore throat

A young male was referred to the ER for an elevated creatinine of 3.4. He was completely healthy otherwise. A PCP, ER APP and ER physician all gave the same history: An elevated creatinine. Out of nowhere. That’s it.

I asked my usual question.

He looked at his wife and then back at me. “Well, I did have a terrible sore throat about two weeks ago.”

Yup, he had post-infectious glomerulonephritis from strep pharyngitis. To be honest, it wasn’t high on my differential when I walked into his room, but my HABIT of asking this question to gather a story got me there quickly. You don’t have to be so smart with a long list of differentials when a good history gives it you.

The Therapeutic Story

That question, and attempting to understand a patient’s story, can expose social and baseline factors related to a chief complaint that the patient or family hasn’t thought of or hasn’t discussed with other providers. Some describe this as “establishing their usual state of health” before stating “they were in their usual state of health until…” That’s okay, but it’s more than that. Understanding their story can lead to an entirely different discussion versus qualifiers of a chief complaint.

It’s at least a monthly occurrence that an elderly patient with dementia is brought in by family for “confusion and falls” and diagnosed with a UTI. My usual question is frequently answered by some version of “Well, he’s actually been on a decline for the last year.” It’s often the first time they’ve admitted it to a provider or even the first time saying it out loud. My favorite question is then, “and then what?” The story becomes clearer to me as they tell it, and often becomes clear to them as they tell it - understanding what options need to be considered before I even mention them.

Then our visit is not just about antibiotics and admission, but discussions of hospice, nursing home placement, and what qualities they value the most. The “chief complaint” becomes almost a footnote and hospitalization not always needed. Obtaining an HPI has then become a therapeutic tool.

The End

To ensure I cap the story, I ask my 2nd favorite question, “what changed that made you come to the hospital today.” Finally, I make sure I know how they got to the hospital. Did they call EMS or drive themselves? That ensures I know the complete story from beginning to end.

Avoid the use of “of note…” because this is typically followed by something out of order. I laugh and cringe every time an HPI ends with an “of note…” that gives the whole HPI new context. You are not setting up cliff hangers for the big reveal at the end.

I also ensure accuracy by repeating the story back to the patient when I’m done. This has three uses

1. This helps tell the chronological story by exposing gaps I may have missed.

2. This assures the patient I’ve accurately obtained their story.

3. Repeating the story sticks it my mind and dictating the HPI is much more efficient.

Finally, patients are increasingly obtaining immediate access to their notes due to open chart laws. The truth is, they may not notice that the HPI is accurate - that’s the expectation. But you can bet they WILL notice if you get details wrong. It’s not infrequent for a patient to ask me to “correct the record” of an H&P written by another physician (which I can’t do, of course).

There’s a term for all of this. It’s called narrative medicine. Columbia University even offers a graduate degree in it. I recently read an article written by Sandeep Jauhar where he wrote that quote, “narratives humanize patients.” Check it out here: Medical records are filled with copy-paste errors - STAT (statnews.com).

So, tell a chronological story from the time*things*changed* up until they came to you. Find the beginning. Go in order, step by step. Don’t have gaps. Know the end.

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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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