Following the
chief complaint The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting pro ...
in
medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other pe ...
taking, a history of the present illness (abbreviated HPI)
(termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example,
pain
Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
).
Questions to include
Different sources include different questions to be asked while conducting an HPI.
Several acronyms have been developed to categorize the appropriate questions to include.
The
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements. An "extended HPI" includes four or more of these elements.
Also usable is
SOCRATES
Socrates (; ; –399 BC) was a Greek philosopher from Athens who is credited as the founder of Western philosophy and among the first moral philosophers of the ethical tradition of thought. An enigmatic figure, Socrates authored no te ...
. For chronic pain, the
Stanford Five may be assessed to understand the pain experience from the patient's primary belief system.
See also
*
Medical record
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdi ...
*
Medical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other pe ...
*
Pain scale
A pain scale measures a patient's pain intensity or other features. Pain scales are a common communication tool in medical contexts, and are used in a variety of medical settings. Pain scales are a necessity to assist with better assessment of pa ...
References
External links
Overview at medicine.ucsd.edu
{{Medical records
Medical terminology