history of present illness nursing

History of Present Illness (HPI)

History of present illness.

• Video Introduction
• History of Present Illness (HPI) Overview
• Psychiatric considerations
• Trauma considerations

Progress notes

Every clinical encounter begins with a  chief complaint. The chief complaint is the primary reason for the patient’s visit. It is considered good practice to record the chief complaint in the patient’s own words (Example: “My chest hurts”).  Acquiring the chief complaint helps you brainstorm a list of differential diagnoses. The goal of your clinical encounter is to narrow this differential list and formulate a plan. The history of present illness (HPI) is the first step in this process. 

The purpose of the history of present illness (HPI) is to build a chronological history of the patient’s illness.   This includes the sequence of events that made the patient seek care and elements associated with their complaint, such as location, character, etc.

A brief HPI has 1 to 3 elements, while an extended HPI includes 4 or more elements. These elements include:

• Radiating pain travels a specific path, often that of a nerve distribution, and is commonly neuropathic. On the other hand,
• Referred pain does not travel / radiate and is generally associated with visceral complaints (Ex. Right shoulder in cholecystitis).

• Character:  The character describes the quality of the complaint. A patient may describe the pain as stabbing, pressure-like, or dull. Diarrhea may be described as oily, watery, or bloody. 
• Severity:  The severity of a complaint is typically rated on a scale of 1 to 10, 10 being the worst pain they have ever experienced. 
• Onset : Includes two components. When the complaint was presented and what the patient was doing then.
• Duration:  The duration of the complaint can be consistent, intermittent (Occurring in irregular intervals), or episodic (Occurring in regular intervals). If episodic, you want to ask about potential triggers (Ex. Postprandial).
• Modifying factors:  Pertains to what makes the complaint worse and what makes it better. It can also include failed attempts to relieve the complaint. 
• Associated symptoms:  Symptoms associated with the complaint should be clarified regarding their onset and relationship with the chief complaint. 

Two commonly used mnemonics for recording HPI are presented in the table below. These mnemonics are best used for pain complaints and as a starting point for clinical rotations. In this app, you can use our template to record your findings. Electing to do so allows the app to generate an HPI sentence.

• Exacerbation & Relieving Factors
• Associated Symptoms
• Alleviating / Aggravating

Psychiatric Considerations

In addition to the elements above, psychiatric HPI should include social aspects of the patient’s life. Components that are typically included in the social history, such as substance use and support system, should be included in the HPI. Such components may provide clues to the underlying condition.  Additionally It is essential to assess how the symptoms affect the patient’s functionality. 

We recommend familiarize yourself with standard questionnaires such as PHQ-9 for depression and GAD-7 for general anxiety disorder. MDCalc is an excellent website for accessing an electronic version of these questionnaires. 

We recommend screening all patients with chronic disease for depression. One of the commonly used mnemonics for depression is SIG E CAPS .

• Sleep: Have there been any changes in your sleep?
• Interest: Have you lost interest in any of your hobbies or activities?
• Guilt:  Do you feel like you are a burden to your family and friends?
• Energy:  Have you noticed any changes in your energy level?
• Concentration: Are you able to stay concentrated on daily tasks?
• Appetit: Have you noticed any changes in your appetite? Have you been gaining or losing weight?
• Psychomotor Activity: Do you feel like your thoughts or actions have been slowing down?
• Suicidal ideation: Have you thought about hurting yourself?

Emergency & Trauma Considerations

The advanced trauma life support (ATLS) manual divides your history during a trauma activation into two parts. Primary assessment and secondary assessment. The trauma team usually handles these assessments as the patient enters the trauma bay. The history is commonly received from the first responders who responded to the scene. During the primary assessment, you’ll focus on 4 main elements. You can modify and apply this to all patient handoffs in the emergency department. The mnemonic for these elements is MIST :

• Mechanism of Injury: How the patient was injured. (Ex. Unrestrained passenger of a motor vehicle accident)
• Injury Pattern: What injuries did the patient suffer during the accident 
• Signs: Include the patient’s vitals, GCS, and other relevant information.
• Treatment given: The treatment that was provided during the patient’s transport. (Ex. a cervical collar was placed)

The secondary assessment, mnemonic AMPL , is done when the patient has been stabilized and includes a llergies, m edications, p ast illnesses, and l ast meals.

Patients who have stayed in the hospital for a day or more will have a comprehensive history and physical note in their chart. These patients require daily progress notes. The components of the progress note is focused on goals of care and barriers to discharge. These elements include:

• Acute events overnight
• Response to therapy
• Level of activity
• Diet restrictions
• New symptoms/concerns
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History of Present Illness

The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive.  Each type of history includes some or all of the following elements:

Key Components

• Chief complaint (CC)
• History of present illness (HPI)
• Review of systems (ROS)
• Past, family and/or social history (PFSH)

Contributory Factors

• Coordination of care
• Nature of presenting problem

Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors.  The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the history table must be met. A chief complaint is indicated at all levels.

Chief Complaint (CC):  A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record.

History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements:

• Location: What is the location of the pain?
• Quality: Include a description of the quality of the symptom (i.e.  sharp pain)
• Severity: Degree of pain for example can be described on a scale of 1 - 10
• Duration: How long have you had the pain
• Timing:  Describe when you have pain for example pain with exertion or pain in evening
• Context: What is the patient doing when the pain begins
• Modifying Factors: What makes the pain better or worse for example aspirin helps
• Associated Signs and Symptoms: Physician based on assessment may ask about other sensations or feelings for example – do you experience pain while exercising
• Brief HPI: Requires one to three HPI elements (see above list)
• Extended HPI: Requires four HPI elements or the status of three chronic problems (see 1997 guidelines for status of chronic conditions)

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History of Present Illness (HPI)

Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially in the coming years as you gain a greater understanding of the pathophysiology of disease through increased exposure to patients and illness. However, you are already in possession of the tools that will enable you to obtain a good history. That is, an ability to listen and ask common-sense questions that help define the nature of a particular problem. It does not take a vast, sophisticated fund of knowledge to successfully interview a patient. In fact seasoned physicians often lose sight of this important point, placing too much emphasis on the use of testing while failing to take the time to listen to their patients. Successful interviewing is for the most part dependent upon your already well developed communication skills.

What follows is a framework for approaching patient complaints in a problem oriented fashion. The patient initiates this process by describing a symptom. It falls to you to take that information and use it as a springboard for additional questioning that will help to identify the root cause of the problem. Note that this is different from trying to identify disease states which might exist yet do not generate overt symptoms. To uncover these issues requires an extensive "Review Of Systems" (a.k.a. ROS). Generally, this consists of a list of questions grouped according to organ system and designed to identify disease within that area. For example, a review of systems for respiratory illnesses would include: Do you have a cough? If so, is it productive of sputum? Do you feel short of breath when you walk? etc. In a practical sense, it is not necessary to memorize an extensive ROS question list. Rather, you will have an opportunity to learn the relevant questions that uncover organ dysfunction when you review the physical exam for each system individually. In this way, the ROS will be given some context, increasing the likelihood that you will actually remember the relevant questions.

The patient's reason for presenting to the clinician is usually referred to as the "Chief Complaint." Perhaps a less pejorative/more accurate nomenclature would be to identify this as their area of "Chief Concern."

Getting Started: Always introduce yourself to the patient. Then try to make the environment as private and free of distractions as possible. This may be difficult depending on where the interview is taking place. The emergency room or a non-private patient room are notoriously difficult spots. Do the best that you can and feel free to be creative. If the room is crowded, it's OK to try and find alternate sites for the interview. It's also acceptable to politely ask visitors to leave so that you can have some privacy.

If possible, sit down next to the patient while conducting the interview. Remove any physical barriers that stand between yourself and the interviewee (e.g. put down the side rail so that your view of one another is unimpeded... though make sure to put it back up at the conclusion of the interview). These simple maneuvers help to put you and the patient on equal footing. Furthermore, they enhance the notion that you are completely focused on them. You can either disarm or build walls through the speech, posture and body languarge that you adopt. Recognize the power of these cues and the impact that they can have on the interview. While there is no way of creating instant intimacy and rapport, paying attention to what may seem like rather small details as well as always showing kindness and respect can go a long way towards creating an environment that will facilitate the exchange of useful information.

If the interview is being conducted in an outpatient setting, it is probably better to allow the patient to wear their own clothing while you chat with them. At the conclusion of your discussion, provide them with a gown and leave the room while they undress in preparation for the physical exam.

Initial Question(s): Ideally, you would like to hear the patient describe the problem in their own words. Open ended questions are a good way to get the ball rolling. These include: "What brings your here? How can I help you? What seems to be the problem?" Push them to be as descriptive as possible. While it's simplest to focus on a single, dominant problem, patients occasionally identify more then one issue that they wish to address. When this occurs, explore each one individually using the strategy described below.

Follow-up Questions: There is no single best way to question a patient. Successful interviewing requires that you avoid medical terminology and make use of a descriptive language that is familiar to them. There are several broad questions which are applicable to any complaint. These include:

• Duration: How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time?
• Severity/Character: How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night? Try to have them objectively rate the problem. If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though first find out what that was so you know what they are using for comparison (e.g. childbirth, a broken limb, etc.). Furthermore, ask them to describe the symptom in terms with which they are already familiar. When describing pain, ask if it's like anything else that they've felt in the past. Knife-like? A sensation of pressure? A toothache? If it affects their activity level, determine to what degree this occurs. For example, if they complain of shortness of breath with walking, how many blocks can they walk? How does this compare with 6 months ago?
• Location/Radiation: Is the symptom (e.g. pain) located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body?
• Have they tried any therapeutic maneuvers?: If so, what's made it better (or worse)?
• Pace of illness: Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change?
• Are there any associated symptoms? Often times the patient notices other things that have popped up around the same time as the dominant problem. These tend to be related.
• What do they think the problem is and/or what are they worried it might be?
• Why today?: This is particularly relevant when a patient chooses to make mention of symptoms/complaints that appear to be long standing. Is there something new/different today as opposed to every other day when this problem has been present? Does this relate to a gradual worsening of the symptom itself? Has the patient developed a new perception of its relative importance (e.g. a friend told them they should get it checked out)? Do they have a specific agenda for the patient-provider encounter?

For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS ( O nset, L ocation/radiation, D uration, C haracter, A ggravating factors, R elieving factors, T iming and S everity).

The content of subsequent questions will depend both on what you uncover and your knowledge base/understanding of patients and their illnesses. If, for example, the patient's initial complaint was chest pain you might have uncovered the following by using the above questions:

The pain began 1 month ago and only occurs with activity. It rapidly goes away with rest. When it does occur, it is a steady pressure focused on the center of the chest that is roughly a 5 (on a scale of 1 to 10). Over the last week, it has happened 6 times while in the first week it happened only once. The patient has never experienced anything like this previously and has not mentioned this problem to anyone else prior to meeting with you. As yet, they have employed no specific therapy.

This is quite a lot of information. However, if you were not aware that coronary-based ischemia causes a symptom complex identical to what the patient is describing, you would have no idea what further questions to ask. That's OK. With additional experience, exposure, and knowledge you will learn the appropriate settings for particular lines of questioning. When clinicians obtain a history, they are continually generating differential diagnoses in their minds, allowing the patient's answers to direct the logical use of additional questions. With each step, the list of probable diagnoses is pared down until a few likely choices are left from what was once a long list of possibilities. Perhaps an easy way to understand this would be to think of the patient problem as a Windows-Based computer program. The patient tells you a symptom. You click on this symptom and a list of general questions appears. The patient then responds to these questions. You click on these responses and... blank screen. No problem. As yet, you do not have the clinical knowledge base to know what questions to ask next. With time and experience you will be able to click on the patient's response and generate a list of additional appropriate questions. In the previous patient with chest pain, you will learn that this patient's story is very consistent with significant, symptomatic coronary artery disease. As such, you would ask follow-up questions that help to define a cardiac basis for this complaint (e.g. history of past myocardial infarctions, risk factors for coronary disease, etc.). You'd also be aware that other disease states (e.g. emphysema) might cause similar symptoms and would therefore ask questions that could lend support to these possible diagnoses (e.g. history of smoking or wheezing). At the completion of the HPI, you should have a pretty good idea as to the likely cause of a patient's problem. You may then focus your exam on the search for physical signs that would lend support to your working diagnosis and help direct you in the rational use of adjuvant testing.

Recognizing symptoms/responses that demand an urgent assessment (e.g. crushing chest pain) vs. those that can be handled in a more leisurely fashion (e.g. fatigue) will come with time and experience. All patient complaints merit careful consideration. Some, however, require time to play out, allowing them to either become "a something" (a recognizable clinical entity) or "a nothing," and simply fade away. Clinicians are constantly on the look-out for markers of underlying illness, historical points which might increase their suspicion for the existence of an underlying disease process. For example, a patient who does not usually seek medical attention yet presents with a new, specific complaint merits a particularly careful evaluation. More often, however, the challenge lies in having the discipline to continually re-consider the diagnostic possibilities in a patient with multiple, chronic complaints who presents with a variation of his/her "usual" symptom complex.

You will undoubtedly forget to ask certain questions, requiring a return visit to the patient's bedside to ask, "Just one more thing." Don't worry, this happens to everyone! You'll get more efficient with practice.

Dealing With Your Own Discomfort: Many of you will feel uncomfortable with the patient interview. This process is, by its very nature, highly intrusive. The patient has been stripped, both literally and figuratively, of the layers that protect them from the physical and psychological probes of the outside world. Furthermore, in order to be successful, you must ask in-depth, intimate questions of a person with whom you essentially have no relationship. This is completely at odds with your normal day to day interactions. There is no way to proceed without asking questions, peering into the life of an otherwise complete stranger. This can, however, be done in a way that maintains respect for the patient's dignity and privacy. In fact, at this stage of your careers, you perhaps have an advantage over more experienced providers as you are hyper-aware that this is not a natural environment. Many physicians become immune to the sense that they are violating a patient's personal space and can thoughtlessly over step boundaries. Avoiding this is not an easy task. Listen and respond appropriately to the internal warnings that help to sculpt your normal interactions.

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The Illness Narrative & HPI

As we gather a patient’s history, we seek to both diagnose their disease and to understand their illness. For lay people, these two terms – illness and disease – may mean the same thing. But for physicians, there is a critical difference.

Illness describes a patient’s unique experience of being sick, which is influenced by biology, context, culture and support system. To provide patient-centered care, we need to understand people’s stories and elicit  their concerns, ideas, needs and expectations about their illness.

Disease, on the other hand, can be defined as a disruption in normal biologic function at the cellular, organ, or system level. To diagnose a disease, we compare the details of our patient’s symptoms and signs with what we know about different disorders, using clinical reasoning to select and test for the most likely.

Most patients with a disease also have an illness – they somehow feel unwell – but many do not. A common example is diabetes, which is asymptomatic in its early stages but causes severe complications if untreated. And different people may be affected very differently by the same disease – their diagnosis is the same, but their illness is not. To optimize a patient’s care, we need to  both   diagnose their disease and understand their illness.

Doctors arrive at most diagnoses based on the patient’s history, even in the modern era. Studies comparing final diagnoses with physicians’ leading diagnoses after the history, after the physical, and after testing, show that most correct diagnoses are suggested by the history.

Eliciting the Illness Narrative

Start with an open ended question about your patient’s primary concern. A question like, “Why don’t you start at the beginning and tell me all about ___” tells your patient you want all the details of the problem. Use verbal or non-verbal continuers, like mmm-hmms or nodding, to encourage them to go on. Open-ended questions, like “what happened then”, gentle directives like “tell me more about that”, or reflecting the last few word of the patient’s last statement can also prompt them to go on.  Ask specifically about how it’s impacting their lives, and what they are hoping for now.

Eliciting a patient’s illness narrative will accomplish three things. First, hearing the story in a patient’s words can be diagnostically useful, painting a clearer picture than the answers to a series of questions. Second, it will provide the context needed to develop a treatment plan. And third, simply telling one’s story can be therapeutic. Even as a first-year student, you can contribute to your patients’ healing simply by listening.

Patient Voices : 

In this New York Times series, different patients with the same disease describe their unique experiences of illness, sharing the impact of disorders like Parkinson’s, ALS, or sickle cell anemia.

Here, we include stories of people living with bipolar disorder. The introduction says “Riding the ups and downs of bipolar disorder can cause havoc for those living with the disorder and their loved ones. Here are firsthand accounts of those living with bipolar disorder.”

Listen with intention to at least two of these stories. How are they similar? How are they different? How would hearing them help you to care for the whole person?

As you listen, think about:

• Who is this patient?
• How does this patient experience this illness?
• What are the patient’s ideas about the cause of the illness?
• What are the patient’s feelings about the illness?
• If applicable, what does the patient want from their healthcare now?

The History of Present Illness (HPI)

The history of present illness organizes a patient’s illness narrative and adds to it to support clinical reasoning. Doctors arrive at most diagnoses based on the patient’s history, even in the modern era. Studies comparing final diagnoses with physicians’ leading diagnoses after the history, after the physical, and after testing, show that most correct diagnoses are suggested by the history.

After eliciting the patient’s narrative, the physician shifts to a different style of inquiry, clarifying details and timeline and asking more questions that could differentiate two possible causes of a symptom. This is sometimes referred to as the ‘physician centered’ part of the interview.

Although there are over 10,000 known human diseases, patients present with fewer than 200 symptoms. A careful, complete and detailed description of the presenting concern will help differentiate among the many possible causes.

Diagnoses suggested by each part of patient encounter 1,2

Eliciting the HPI

Start with the illness narrative.

After greeting the patient, establishing the chief concern, and discussing the agenda, start the patient’s narrative with an open-ended question or request.

Guide the story and explore the details

Next, draw out more of the patient’s illness narrative, guiding them with more open questions, gentle directives, and reflections. Your goals are to:

• elicit a complete and precise description of the symptoms
• clarify the time course
• understand the patient’s perspective and impact of the illness

Summarize what you’ve heard to check for accuracy and encourage the patient to share any details they may have left out.

Follow up with closed-ended questions

Switch to closed-ended questions about symptoms or risks that might differentiate between the diseases you’re considering. As a first-year student, you can simply ask about other symptoms from the organ system that you think is causing your patient’s problem. The Review of Systems section below will help.

Explore patient perspective and attribution

The patient’s perspective is an important – and often overlooked – element of the history, including their feelings, ideas and concerns about their illness and its impact on their daily lives.

Attribution refers to your patient’s ideas about the reason for their symptoms – ask “what do you think might be causing this?” The answer to this question is sometimes diagnostically helpful – your patient might be right! Attribution also provides insight into their underlying concerns and cultural context that could impact care.

You can also explore the impact of the illness on your patient’s life, with questions like:

• How has this affected your life?
• How are you coping with all of this?
• How has this affected your ability to do what you need to do?
• How has this impacted you emotionally?

Example HPI

Eliciting the hpi: helpful tools, communication techniques.

Consider a patient presenting with abdominal pain – a careful history can limit the possibilities substantially. Severe pain that came on suddenly would lead you to consider different diagnoses than mild, intermittent pain. The list of diseases that cause pain in the upper right abdomen is different from those that cause pain on the left. Relief with antacids would suggest heartburn or ulcers. Each of these details can be diagnostically useful – and you can gather them even before learning about causes of this chief concern.

Establish a clear chronology

The diseases that cause acute and chronic presentations of the same symptom are often different. In general, a symptom with a “sudden” onset came on over minutes; an acute symptom over hours to days; subacute over weeks to a few months; and a chronic symptom has been present for longer than several months.

Understanding the acuity of symptoms both helps with diagnosis and determines the urgency of the workup. A patient who has had similar headaches for years is unlikely to have a severe problem, but new onset headache could be something serious.

The temporal relationship between different symptoms and treatments can also be diagnostically useful. For example, patients with infectious gastroenteritis usually develop nausea or diarrhea first, before they have any abdominal pain. Those with surgical problems usually develop pain first. Be sure you understand which symptom came first and how others followed.

If the time course of your patient’s illness is unclear, clarify it by asking questions like:

• When did you last feel well?
• What was the first thing you noticed?
• What happened next?
• How have things changed since (start of symptoms)?

Transition to the past medical history

Once you have a complete picture of the HPI, summarize one more time and check to see if there is anything else that your patient would like to add. Then transition explicitly to the next stage of the interview, with a signpost like “Next I’d like to ask about other health problems you may have.”

Reference & resources

Street RL, Makoul G et al (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling. 74(3):295-301  LINK

Patient Voices – The New York Times (nytimes.com)

Peterson, MC, Holbrook, JH, Von Hales, D, Smith, NL, Staker, LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses . West J Med. 1992 ;156: 163 – 165 .

Hampton, JR, Harrison, JM, Mitchell, JR, Prichard, JS, Seymour, C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients . Br Med J. 1975 ;2: 486 – 489

The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.

History of Present Illness

• First Online: 15 December 2009

Cite this chapter

• James Binder MD 2  

Part of the book series: Current Clinical Practice ((CCP))

1070 Accesses

Eighteen seconds. Maybe 23 s. That’s all the time an average patient has to tell his story before he is interrupted. Seventy percent of patients never get to finish their story [1, 2]. Why? The obvious answer: physicians feel rushed for time. However, that does not explain the 18 s fully. Why not interrupt after 2 s? I think the 18 s is a cursory attempt to listen to the patient before moving to the real task of the interview: gather symptom data needed for diagnosis. It is a false dichotomy. During the opening phase, the clinician listens to the patient and begins to gather psychosocial and biological data needed for accurate diagnosis (see Chap. 2). This takes 3-5 min to accomplish, not 18 s. The clinician listens to the patient and gathers data during the second phase of the interview as well. Only, the emphasis shifts to gathering the data that the patient does not spontaneously offer and that the clinician needs for accurate diagnosis.

What else could it be? is a key safeguard against these errors in thinking: premature closure, framing effect, availability from recent experience, the bias that the hoof beats are horses and not zebras. … So a thinking doctor returns to language. ‘Tell me the story again as if I never heard—what you felt, how it happened, when it happened.

Jerome Groopman, How Doctors Think

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Binder, J. (2010). History of Present Illness. In: Pediatric Interviewing. Current Clinical Practice. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60761-256-8_3

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Chapter 5:  History of Present Illness for Common Symptoms

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Introduction, abdominal pain.

• CONSTIPATION
• DEPRESSED MOOD
• GENITOURINARY DISCHARGE
• MOTOR VEHICLE COLLISION
• NAUSEA/VOMITING
• PERIPHERAL EDEMA
• SORE THROAT
• UPPER RESPIRATORY INFECTION
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The history of present illness (HPI) is also called the primary history. It is a detailed set of questions designed to elaborate on the patient’s chief complaint or presenting symptom. An accurate history is the first step in determining the etiology of the patient’s concern. In fact, frequently, the diagnosis can be made simply on the history and physical examination.

There are several general questions that are applicable to most symptoms. Many acronyms have been proposed for memorizing the elements of the HPI. The one we include here is the OLD CARTS method:

C haracteristics

A ggravating factors

R elieving Factors

T reatments tried

S ymptoms associated

Remember that an accurate history is not only important in determining the diagnosis, but is essential for proper reimbursement. The Centers for Medicare and Medicaid Services has defined criteria for what qualifies as a “reimbursable” HPI. A brief HPI includes one to three of the following, whereas an extended HPI must include four or more elements.

Timing O nset

Quality ( C haracteristics)

Severity ( C haracteristics)

Context ( O nset)

Modifying factors ( A ggravating/ R elieving factors)

Associated signs and symptoms ( S ymptoms associated)

Included in this chapter are many of the acute symptoms most commonly encountered in clinical practice. The questions are designed to elicit a differential diagnosis for each complaint. Of course, not all the elements of the OLD CARTS questions can be applied to all symptoms; for example, insomnia has no location. But wherever possible, we attempted to incorporate as many questions as were appropriate to each symptom.

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How to take a history of present illness for abdominal pain

Before we get into how to take a history of present illness, let’s first review the components of a medical evaluation. Information from a medical evaluation (written medical documentation and verbal patient presentations) is typically relayed in a structured way. Although the format may vary slightly from region to region, most clinicians follow a similar template.

One such template lists four components of a medical evaluation and uses the acronym SOAP:

The SOAP evaluation is a basic form of communication that can be expressed verbally and in written form. Each part of the SOAP builds on the previous section. It starts with the healthcare provider recording observations of a subjective nature. This is followed by the measurement of objective information so that an assessment of the problem can be made, and a plan can be created for it.

The subjective portion of the SOAP is based on observations from the patient. It contains the history of present illness (HPI) as well as the patient’s chief complaint and associated symptoms. The chief complaint is the primary reason for the patient presenting to a healthcare professional.

The objective portion contains measured information and is therefore not subjective. This portion contains vital signs, lab tests, diagnostic imaging, and a physical exam (including the abdominal exam).

The assessment portion is a summative section that provides the diagnosis, or at least the differential diagnosis. Based on the information from both the subjective and objective sections, this portion notes what the disease or condition might be.

The plan section refers to how the patient’s problem or condition will be addressed. For example, the plan for a patient assessed to have acute appendicitis is to perform an appendectomy, give pain medications, and prescribe antibiotics.

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How to gather a history of present illness.

The history of present illness, or HPI, is part of the subjective portion of the patient interview and provides detailed information on the patient’s chief complaint. For example, if someone presents with a cough, the HPI would record details about the cough from the patient in their own words.

The HPI can be organized into the acronym OLD CARTS that contains eight sections:

Alleviating factors

Temporal patterns.

Question: When did the pain start?

When asking about the onset, you should determine exactly when the pain started. Be very specific with your questions to the patient. Did it start one week ago or two days ago? Did it start today? If so, when—in the morning or the afternoon?

Question: Where is the pain located?

Next, determine the location of the pain. Again, be very specific with your questions. It is important to localize the pain as best you can during the subjective portion. Localization will set you up for success during the physical exam portion.

Ask the patient about specific regions such as the right upper quadrant, right lower quadrant, left upper quadrant, left lower quadrant, epigastrium, and suprapubic regions. As well, ask the patient to point to the area where the pain hurts the most using a single finger. Where they point may surprise you because it forces the patient to really think about the location. Keep in mind, the location may not line up with what they initially said!

Question: How long have you had the pain?

Next, determine how long the patient has had the pain . Again, be specific and ask how many hours, days, weeks, or months they have had the pain. The onset of pain is important to help determine if it has an acute or chronic nature.

Question: Can you describe the pain?

Pain always has a character to it; you just have to ask and be specific with the patient. The character of the pain is also known as the type of pain. There are several ways we can characterize pain:

Question: What helps the pain, and what makes it worse?

Ask your patient if certain things alleviate or worsen the pain. This might include different positions such as sitting, standing, laying down, moving, or not moving. Inquire about the use of medications such as nonsteroidal anti-inflammatory drugs.

Ask what happens if they consume certain foods such as fatty, greasy, spicy, acidic, or milk-containing foods. Also, ask about the consumption of caffeinated beverages and alcohol.

Radiation of the pain

Question: Does the pain radiate anywhere?

As part of the HPI, ask the patient if the pain radiates to other locations of the body such as the back, neck, shoulders, or arms.

Question: Does the pain show any patterns as to when it recurs?

Ask the patient if their pain has a specific pattern of recurrence. Does it appear every morning or night? Is it happening after a fatty meal, after consuming dairy products, drinking a cup of coffee, or eating spicy, acidic food?

Question: Are any other symptoms associated with the pain?

Lastly, you’ll want to ask if there are any other symptoms associated with the pain. Ask whether these symptoms occur before, after, or during the pain. Ask if there is any associated nausea, vomiting, or diarrhea.

Remember that the pain could be stemming from several different organ systems, including the gastrointestinal (GI), urinary, and reproductive systems. So, make sure to include questions about each of these systems when inquiring about associated symptoms.

What associated symptoms should you ask about?

As mentioned previously, there are several organ systems in the abdomen. The patient may not realize that other symptoms are associated with the pain. You must guide them by asking them direct questions.

Associated GI symptoms

Start by asking about GI symptoms such as heartburn, constipation, nausea, vomiting, anorexia, reflux, and diarrhea. However, you will want to think through these symptoms to determine which may be related to the chief complaint. Some symptoms may fit with the chief complaint and some may not. So, you have to ask about a large variety of symptoms.

Asking broad questions allows you to initially understand which symptoms the patient has and which they don’t have. Then, you can begin to narrow down what the source of their pain may be based on their answers.

Associated gynecological symptoms

In women experiencing abdominal pain, you also need to inquire about associated gynecological symptoms. Ask about symptoms such as pelvic pain, abnormal vaginal discharge, pain with intercourse (e.g., dyspareunia), and painful periods (e.g., dysmenorrhea).

Associated urological symptoms

Bladder and kidney infections are just two of the many urological issues that present as abdominal pain. So, you also need to ask about urologic symptoms in men and women. Ask the patient if they have flank pain (pain in the lower back or side), pain with urination (e.g., dysuria), incomplete micturition (where they are unable to completely void), blood in their urine (e.g., hematuria), or frequent urination.

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account , which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

• de Dombal, FT. 1988. The OMGE acute abdominal pain survey. Progress report, 1986.  Scand J Gastroenterol Suppl .  144 : 35–42.  PMID: 3043646
• Jin, XW, Slomka, J, and Blixen, CE. 2002. Cultural and clinical issues in the care of Asian patients.  Cleve Clin J Med .  69 : 50, 53–54, 56–58.  PMID: 11811720
• Tseng, W-S and Streltzer, J. 2008. “Culture and clinical assessment”. In:  Cultural Competence in Health Care . Boston: Springer. 
• Wong, C. 2020. Liver fire in traditional Chinese medicine.  verywellhealth .  https://www.verywellhealth.com

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Vivek Podder ; Valerie Lew ; Sassan Ghassemzadeh .

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• Introduction

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way. [1] [2] [3]

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record. [4] [5] [6]

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below.

This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.

Chief Complaint (CC)

The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

• Examples: chest pain, decreased appetite, shortness of breath.

However, a patient may have multiple CC’s, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all of their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis.

History of Present Illness (HPI)

The HPI begins with a simple one line opening statement including the patient's age, sex and reason for the visit.

• Example: 47-year old female presenting with abdominal pain.

This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
• Alleviating and Aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?

It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than include excessive detail.

• Medical history: Pertinent current or past medical conditions
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient's family.
• Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

Review of Systems (ROS)

This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.

• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, decreased right shoulder range of motion

Current Medications, Allergies

Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often. 

• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days

This section documents the objective data from the patient encounter. This includes:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.

A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.

This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.

List the problem list in order of importance. A problem is often known as a diagnosis.

Differential Diagnosis

This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

• Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Repeat for additional problems

This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:

• State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative
• Therapy needed (medications)
• Specialist referral(s) or consults
• Patient education, counseling

A comprehensive SOAP note has to take into account all subjective and objective information, and accurately assess it to create the patient-specific assessment and plan.

• Issues of Concern

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order. For instance, rearranging the order to form APSO (Assessment, Plan, Subjective, Objective) provides the information most relevant to ongoing care at the beginning of the note, where it can be found quickly, shortening the time required for the clinician to find a colleague's assessment and plan. One study found that the APSO order was better than the typical SOAP note order in terms of speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Re-ordering into the APSO note is only an effort to streamline communication, not eliminate the vital relationship of S to O to A to P.

A weakness of the SOAP note is the inability to document changes over time. In many clinical situations, evidence changes over time, requiring providers to reconsider diagnoses and treatments. An important gap in the SOAP model is that it does not explicitly integrate time into its cognitive framework. Extensions to the SOAP model to include this gap are acronyms such as SOAPE, with the letter E as an explicit reminder to assess how well the plan has worked. [7] [8] [9] [10]

• Clinical Significance

Medical documentation now serves multiple needs and, as a result, medical notes have expanded in both length and breadth compared to fifty years ago. Medical notes have evolved into electronic documentation to accommodate these needs. However, an unintended consequence of electronic documentation is the ability to incorporate large volumes of data easily. These data-filled notes risk burdening a busy clinician if the data are not useful. As importantly, the patient may be harmed if the information is inaccurate. It is essential to make the most clinically relevant data in the medical record easier to find and more immediately available. The advantage of a SOAP note is to organize this information such that it is located in easy to find places. The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow.

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Disclosure: Vivek Podder declares no relevant financial relationships with ineligible companies.

Disclosure: Valerie Lew declares no relevant financial relationships with ineligible companies.

Disclosure: Sassan Ghassemzadeh declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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• Toward Medical Documentation That Enhances Situational Awareness Learning. [AMIA Annu Symp Proc. 2016] Toward Medical Documentation That Enhances Situational Awareness Learning. Lenert LA. AMIA Annu Symp Proc. 2016; 2016:763-771. Epub 2017 Feb 10.
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2 Health History

Learning objectives.

• Describe the purpose of a health history
• Enumerate the components of a health history.
• Discuss how culture, age and ethnicity influence obtaining a health history.
• Demonstrates therapeutic communication when obtaining a  health history.
• Obtain a comprehensive health history
• Document the results of the health history

Overview of this chapter

This chapter presents the importance of a health history as a component of health assessment and the value of a health history obtained from the perspective of a nurse. This chapter will provide information on components of a health history, considerations in obtaining a health history and documentation.

Health History

The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).

Subjective Data

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012). The health history is the subjective data collection portion of the health assessment.

Components of a Health History

The health history obtained by nurses is framed from holistic perspectives of all factors that contributes to the patient’s current health status. The most common way of obtaining information is through an interview, primarily of the patient. When the patient is unable to provide information for various reasons, the nurse may obtain it from secondary sources.

Knowledge Check:

The checklist below provides steps of obtaining a nursing history based that reflects its components such as biographical data, reason for seeking care, history of present illness, past health history, family history, functional assessment, developmental functions and cultural assessment.  Each healthcare facility will have electronic and/or paper forms based on these components.

Interview Guide

Introductory Information: Demographic and Biographic Data

Name/contact information and emergency information

• What is your full name?
• What name do you prefer to be called by?
• What is your address?
• What is your phone number?
• Who can we contact in an emergency? What is their relationship to you? What number can we reach them at?

Birthdate and age

• What is your birthdate?
• What is your age?
• Tell me what gender you identify with.
• What pronouns do you use? (If the person asks you to use a pronoun that you are not familiar with, it is okay for you to respectfully respond, “I am not familiar with that pronoun. Can you tell me more about it?”)
• Do you have any allergies?
• If so, what are you allergic to?
• How do you react to the allergy?
• What do you do to prevent or treat the allergy?

Note: You may need to prompt for information on medications, foods, etc.

Languages spoken and preferred language

• What languages do you speak?
• What language do you prefer to communicate in (verbally and written)?

Note: You may need to inquire and document if the client requires an interpreter.

Relationship status

• Tell me about your relationship status?

Occupation/school status

• What is your occupation? Where do you work?
• Do you go to school?

Resuscitation status

• We ask all clients about their resuscitation status, which refers to medical interventions that are used or not used in the case of an emergency (such as if your heart or breathing stops). You may need more time to think about this, and you may want to speak with someone you trust like a family member or friend. You should also know that you can change your mind. At this point, if any of this happens, would you like us to intervene?  

Main Health Needs (Reasons for Seeking Care)

Presenting to a clinic or a hospital emergency or urgent care (first point of contact)

• Tell me about what brought you here today.
• Tell me more.
• How is that affecting you?

Already admitted, and you are starting your shift

• Tell me about your main health concerns today.

The PQRSTU Mnemonic

Provocative

• What makes your pain worse?
• What makes your pain feel better?
• What does the pain feel like?
• How bad is your pain?
• Where do you feel the pain?
• Point to where you feel the pain.
• Does the pain move around?
• Do you feel the pain elsewhere?
• How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?
• When did the pain start?
• What were you doing when the pain started?
• Where were you when the pain started?
• Is the pain constant or does it come and go?
• If the pain is intermittent, when did it last occur?
• How long does the pain last?
• Have you taken anything to help relieve the pain?
• Have you tried any treatments at home for the pain?

Understanding

• What do you think is causing the pain?

Current and Past Health

Current health

• Are there any other issues affecting your current health?

Childhood illnesses

• Tell me about any significant childhood illnesses that you had.
• When did it occur?
• How did it affect you?
• How did it affect your day-to-day life?
• Were you hospitalized? Where? How was it treated?
• Who was the treating practitioner?
• Did you experience any complications?
• Did it result in a disability?

Chronic illnesses

• Tell me about any chronic illnesses you currently have or have had (e.g., cancer, cardiac, hypertension, diabetes, respiratory, arthritis).
• How has the illness affected you?
• How do you cope with the illness?
• When were you diagnosed?
• How was the illness being treated?
• Have you been hospitalized? Where?
• Have you experienced any complications?
• Has the illness resulted in a disability?
• How does the illness affect your day-to-day life?

Acute illnesses, accidents, or injuries

• Tell me about any acute illnesses that you have had.
• Tell me about any accidents or injuries you currently have or have had.
• Were you hospitalized? Where?
• How was it treated?
• Has it resulted in a disability?

Obstetrical health

• Have you ever been pregnant?
• Do you have plans to get pregnant in the future?
• Tell me about your pregnancies.
• Have you ever had difficulty conceiving?
• How was your labour and delivery?
• Tell me about your postpartum experience.
• Were there any issues or complications?

Mental Health and Mental Illnesses

Mental health is an important part of our lives and so I ask all clients about their mental health and any concerns or illnesses they may have.

Mental health

• Tell me about your mental health.
• Tell me about the stress in your life.
• How does stress affect you?
• How do you cope with this stress? (this may include positive or negative coping strategies.)
• Have you experienced a loss in your life or a death that is meaningful to you?
• Have you had a recent breakup or divorce?
• Have you recently lost your job or been off work?
• Have you recently had any legal issues?
• Have you purchased any weapons?

Mental illness

• How does that illness affect you?
• How does that illness affect your day-to-day life?
• What resources do you draw upon to cope with your illness?
• Tell me about your treatment (e.g., medications, counselling).
• Do you have any concerns that have not been addressed related to your illness?

Functional Health

• Tell me about your diet.
• What foods do you eat?
• What fluids do you drink? (Probe about caffeinated beverages, pop, and energy drinks.)
• What have you consumed in the last 24 hours? Is this typical of your usual eating pattern?
• Do you purchase and prepare your own meals?
• Tell me about your appetite. Have you had any changes in your appetite?
• Do you have any goals related to your nutrition?
• Do you have the financial capacity to purchase the foods you want to eat?
• Do you have the knowledge and time to prepare the meals you want to eat?

Elimination

• How often do you urinate each day?
• What colour is it (amber, clear, dark)?
• Have you noticed a strong odour?
• How often do you have a bowel movement?
• What colour is it (brown, black, grey)?
• Is it hard or soft?
• Do you have any problems with constipation or diarrhea? If so, how do you treat it?
• Do you take laxatives or stool softeners?

Sleep and rest

• Tell me about your sleep routine.
• How much do you sleep?
• Do you wake up at all?
• Do you feel rested when you wake? What do you do before you go to bed (e.g., use the phone, watch TV, read)?
• Do you take any sleep aids?
• Do you have any rests during the day?

Mobility, activity, exercise

• Tell me about your ability to move around.
• Do you have any problems sitting up, standing up or walking?
• Do you use any mobility aids (e.g., cane, walker, wheelchair)?
• Tell me about the activity and/or exercise that you engage in. What type? How frequent? For how long?

Violence and trauma

• Many clients experience violence or trauma in their lives. Can you tell me about any violence or trauma in your life?
• How has it affected you?
• Tell me about the ways you have coped with it.
• Have you ever talked with anyone about it before?
• Would you like to talk with someone?

Relationships and resources

• Tell me about the most influential relationships in your life.
• Tell me about the relationships you have with your family.
• Tell me about the relationships you have with your friends.
• Tell me about the relationships you have with any other people.
• How do these relationships influence your day-to-day life? Your health and illness?
• Who are the people that you talk to when you require support or are struggling in your life?

Intimate and sexual relationships

• I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships.
• Tell me about the ways that you ensure your safety when engaging in intimate and sexual practices.
• Do you have any concerns about your safety?

Substance use and abuse

• To better understand a client’s overall health, I ask everyone about substance use such as tobacco, herbal shisha, alcohol, cannabis, and illegal drugs.
• Do you or have you ever used any tobacco products (e.g., cigarettes, pipes, vaporizers, hookah)? If so, how much?
• When did you first start? If you used to use, when did you quit?
• Do you drink alcohol or have you ever? If so, how often do you drink?
• How many drinks do you have when you drink?
• When did you first start drinking? If you used to drink, when did you quit?
• Do you use or have you used any cannabis products? If so, how do you use them? How often do you use them?
• When did you first start using them?
• Do you purchase them from a regulated or unregulated place?
• If you used to use cannabis, when did you quit?
• Do you use any illegal drugs? If so, what type? How often do you use them?
• Tell me about the ways that you ensure your safety when using any of these substances.
• Have you ever felt you had a problem with any of these substances?
• Do you want to quit any of these substances?
• Have you ever tried to quit?

Environmental health and home/occupational/school health

• Tell me about any factors in your environment that may affect your health. Do you have any concerns about how your environment is affecting your health?
• Tell me about your home. Do you have any concerns about safety in your home or neighbourhood?
• Tell me about your workplace and/or school environment.
• What activities are you involved in or what does your day look like?

Self-concept and self-esteem

• Tell me what makes you who you are.
• Are you satisfied about where you are in your life?
• Can you share with me your life goals?
• Please explain.
• Tell me about how you take care of yourself and manage your home.
• Do you have sufficient finances to pay your bills and purchase food, medications, and other needed items?
• Do you have any current or future concerns about being able to function independently?

Preventive Treatments and Examinations  

Medications

• Do you have the most current list of your medications?
• Do you have your medications with you? (If not, you should ask them to list each medication they are prescribed and if they know, the dose and frequency.)
• Can you tell me why you take this medication?
• How long have you been taking this medication?
• Do you take the medications as prescribed? (If they answer “no” or “sometimes,” ask them to tell you the reasons for not taking the medications as prescribed.)

Examination and diagnostic dates

• When was the last time you saw [name the primary care provider, nurse or specialist]?
• Can you share with me why you saw them?
• When was the last time you had your [name screening] tested?
• Do you know what the results were?

Vaccinations

• Can you tell me about your immunization status?
• Can you tell me what immunizations you have had, the dates you received them, and any significant reactions?
• Do you have your immunization record?
• When was your last flu vaccine?

If the client’s immunizations are not up-to-date or you noted vaccination hesitancy, you may ask:

• Can you tell me the reasons that your immunizations are not up-to-date?
• Can you tell me why you are hesitant to receive immunizations. (You may need to explore this further.)  

Family Health

• Do they have any chronic or acute diseases (e.g., cardiac, cancer, mental health issues)?
• If so, do you know the cause of death?
• And at what age did they die?
• Has anyone been sick recently?
• If so, do you know the cause?
• What symptoms have they had?
• Have you been around anyone else who was sick recently (e.g., at work, at school, in a location that involved a close encounter such as a plane or an office)?

Cultural Health

• I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?
• How does that affect your health and illnesses?
• Is there anything else you want to share about how these factors act as resources in your life?

Learning Resource:  Open the link below for more detailed information.

The Complete Subjective Health Assessment

Cultural factors in obtaining a health history

When interviewing a patient the nurse must be aware of cultural barriers and preferences in order to collect significant and complete subjective data.. For example due  to age, culture, or ethnicity, some patients may believe that pain is to be expected and endured. The patient may not identify their pain as worthy of report unless the nurse is sensitive to this potential barrier of care. Due to age, culture or ethnicity, some patients may feel uncomfortable discussing sexual health. For example, where HIV is epidemic, it is the nurse’s responsibility (along with all other healthcare personal) to uncover risk factors that can address safety and early treatment for STIs (sexually transmitted diseases). Culture can have many meanings. Some of the many aspects that nurses need to be aware of that will impact information obtained in a health history include gender  identity,  religion,  geographical region, and many diverse factors.   The nurse must be open to learning about various cultures and ethnicity and be comfortable in initiating a cultural assessment, and use this knowledge to enhance communication to obtain the most accurate health history.

Health history and therapeutic communication

Needless to say, therapeutic communication techniques are essential in obtaining a health history. However, due to many reasons, healthcare professionals, including nurses, oftentimes fail to establish a therapeutic relationship or to deliver therapeutic communication. The following are examples :

• Have you ever been to see a healthcare provider and when they walk in the room they are not looking at you but are looking at the chart, or tapping on a computer.
• Have you ever felt rushed by their questions, like they are in a hurry and need to move on to the next patient?
• Have you ever had the healthcare provider give you a diagnosis, provide you with a treatment and you left with a prescription but you didn’t grasp the entire explanation?

The nurse should apply communication and interpersonal skills to create, maintain, and terminate a nurse-client relationship. [] Nurses and other healthcare professionals need to use therapeutic communication techniques at all times.

Open the link below for more detailed information

Therapeutic Communication

Documentation of Health History:

The patient’s health history is initially obtained during admission or initial visit, and constantly updated with subsequent interactions or visits. Documentation of information obtained during the nurse-patient interview, and/or secondary sources will need to be documented on a format that the healthcare facility uses. Nowadays, most healthcare facilities use electronic health records (EHR). EHRs are accessed by various members of the healthcare team in real-time, and this indicates that information obtained can be recorded during the interview process as well. The nurse needs to develop the competency to maintain therapeutic communication techniques while attending to the electronic health record keeping.  Healthcare facilities use different documentation systems. Nurses will need to learn facility specific documentation system, whether electronic or paper, but the contents of a patient history will largely be similar.

Learning Exercises

LaPierre, D. (2010). Clinical assessment. Sharing in health.ca:open access training in healthcare.Retrieved at http://www.sharinginhealth.ca/clinical_assessment/clinical_assessment.html

Nursing Documentation https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/NurseDocumentationPPT.pdf

Sharma, N and Gupta, V ( 2021). Therapeutic Communication. https://www.statpearls.com/articlelibrary/viewarticle/127665/?utm_source=pubmed&utm_campaign=reviews&utm_content=127665#

Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care(8th ed.). Philadelphia: Wolters Kluwer Health.

Wilson, S., Giddens, J., (2013). Health assessment for nursing

https://pressbooks.library.ryerson.ca/documentation/

Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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How to Take a Patient History with OLD CARTS

Table of contents.

What are the Key Elements of a Patient History? 

Taking any patient history begins with what brings the patient in today, better known as a history of present illness (HPI). In general, the HPI is followed by a more comprehensive history, which includes a “chief concern,” past medical history (including chronic illnesses, surgeries, obstetric history, and hospitalizations), family history, social history, medications, allergies, and a “review of systems.” All of these elements comprise the basic pieces of the “history” portion of a history and physical. 

FREE Download: Taking a patient history with OLDCARTS

Related videos, what is the history of present illness .

The history of present illness, better known by the abbreviation “HPI,” is a summary of the illness that led a patient to seek care, whether in the emergency department, being admitted to the hospital, or coming to an outpatient clinic appointment.

It is meant to be concise, but relatively comprehensive, and can often be the most critical aspect of history taking that aids in making a diagnosis. When taking the HPI, it’s crucial to allow the patient time to explain what happened that led to their presentation in their own words. However, there are a few important elements you should attempt to tease out in order to best characterize a patient’s presenting complaint. 

What is OLD CARTS? 

OLD CARTS is a common mnemonic used to remember the “key elements” of the HPI. It stands for O nset, L ocation, D uration, C haracter, A ggravating/ R elieving factors, T iming, and S everity. 

Keeping in mind the OLD CARTS mnemonic is a great way to avoid missing crucial information when it comes to the HPI. Frequently, the information you collect from asking the OLD CARTS questions can be enough to lead to a diagnosis! 

Onset deals with the start of the patient’s condition. Try to determine whether the problem is new (acute), old (chronic), or somewhere in between. Knowing this can often mean the difference between an emergency and something that can be addressed with routine follow-up. 

Location is exactly what it sounds like: where the sensation or pain is felt. Asking about location is most critical for pain-related complaints, but it can also be helpful in certain conditions such as visual symptoms (one eye or both, for instance). 

Duration attempts to determine for t how long the condition has lasted. For instance, if the patient has chest pain, has it been constant for hours, or does it come and go for seconds? The difference will help to direct the rest of your history and physical exam.

Character is often used with pain concerns to better categorize the pain. Burning pain might indicate nerve injury, while dull, achy pain might accompany a heart attack. 

Aggravating/Relieving factors can be helpful hints to determine what makes a condition better or worse. Shortness of breath that’s worse with exertion might indicate angina.

Timing is another time-related element to help determine when a symptom occurs. For example, stomach pain always felt after eating might have a different cause than before or during eating. 

Severity is often graded on a 1-10 scale, but it can also be measured subjectively. An example is a patient who describes the “worst headache of my life” — a classical association with subarachnoid hemorrhage. 

What Other Elements are Important to the Patient History? 

Although OLD CARTS is a great place to start, you will also need to collect additional information in order to take a comprehensive patient history.

Often, the answers to certain questions in OLD CARTS will prompt additional questions and could blend with other elements of the patient history. For instance, a patient with chest pain may mention that the pain feels similar to a previous heart attack (past medical history), a patient with a rash may mention they were recently prescribed an antibiotic (allergies), or a patient might present with a worsening cough and fever after travel to a foreign country (social history).

Tips for Efficient History Taking

Being fluid but comprehensive in taking a history is a skill that can be more of an art than a science. Although taking a full patient history contains all of the items listed above, you might not always obtain the information listed in that order. Keeping a notecard or list of the elements above can be a helpful aid for ensuring that you are asking all the questions you need to in order to get a full picture of your patient’s health. Here are some other tips for success in history taking: 

Ask open-ended questions

Asking a question like “what brings you in today?” can be a great introduction to what’s going on with the patient. Generally, the patient will offer many components of the “OLD CARTS” questions spontaneously when they give an answer to the initial question! This also cuts down on the number of questions you need to ask — spend your time asking clarifying questions based on what they tell you in the initial answer.

Give the patient time to answer

Hand-in-hand with open-ended questioning is the need to give patients plenty of time to respond. One study found that doctors on average interrupt patients in under 23 seconds ! A better strategy is to give the patient plenty of time to tell their story before interrupting. This avoids the patient having to repeat themselves and allows you to focus on relevant details and to zero in on important aspects that otherwise can be missed. 

Become comfortable with pauses

Sometimes, a patient will need to pause to think about the answer to a question you ask. One useful trick is to count to 10 in your head before interrupting, which will usually prompt the patient to continue their story without getting off track. Pauses are essential to helping the patient devise a narrative that can help you uncover a diagnosis that you otherwise might have missed.

Summarize and reflect what you’ve heard

When the patient is done telling their story, summarize what you’ve heard and reflect it back to them, giving them an opportunity to correct or clarify their history. This serves two purposes: it ensures the information that you’ve gathered is accurate, and it also ensures that the patient feels heard and understood, putting them at ease. Summarizing the possible diagnosis, planned workup, or next steps can also help set expectations for any care to immediately follow the patient interview. 

Feel free to return to the patient to ask follow-up or clarifying questions

Sometimes during the course of a patient’s illness, new information, whether from labs, imaging, or other studies, comes to light that can change your framing of the patient’s diagnosis. If a patient is hospitalized, you can always return to the bedside to ask follow-up or clarifying questions in light of new information, or even if you just forgot to ask a question during the initial patient interview. 

Don’t forget the “soft skills”

Active listening by nodding, making eye contact, and avoiding distractions such as looking at a computer during the interview can be just as important as the questions you ask during the interview. Learning to read a patient’s body language can be helpful for identifying subtle clues to the patient’s history. This can be particularly important when identifying cases of possible abuse or trauma. It can also be useful for assessing the patient’s emotional state; fear, confusion, or uncertainty can all be identified by non-verbal cues. During the interview, make sure to observe the patient’s body language, as well as what they’re saying directly, to pick up on clues you might otherwise have missed. 

Taking a full patient history might seem daunting the first few times you try it. With plenty of practice, it becomes second nature. Keep a list handy of the categories of questions to ask until you get used to history taking, and use the OLD CARTS mnemonic to get yourself started. Before you know it, you’ll be taking a history like a pro!

Dr. Brennan Kruszewski is a practicing internist and primary care physician in Beachwood, Ohio. He graduated from Emory University School of Medicine in 2018, and recently completed his residency in Internal Medicine at University Hospitals/Case Western Reserve University in Cleveland. He enjoys writing about a variety of medical topics, including his time in academic medicine and how to succeed as a young physician. In his spare time, he is an avid cyclist, lover of classical literature, and choral singer.

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