History of Present Illness Example: Free H&P Template

What You Need to Know

• A history of present illness example is the worked clinical paragraph that follows the chief complaint, written by the provider through eight defined descriptors.
• Outpatient progress notes grew longer and more redundant over a decade, and template design is one fix.¹
• Use this H&P template, scaffolded to OLDCARTS with three worked history of present illness examples, as a starting point for your specialty.

Download the H&P template (with HPI section)

Note: This template is for informational purposes only and does not constitute legal or medical advice. Have your compliance officer review it before clinical use.

• Download the H&P Template. Editable template with an OLDCARTS-scaffolded history of present illness example section.

Customize it for your specialty and EHR before going live.

What is a history of present illness?

The HPI sits at the front of most outpatient charts, just after the chief complaint. It lives in the Subjective section of a SOAP note and in the History block of an H&P.² The eight elements that make up an HPI have stayed constant even as the chart format around them moved from paper to EHR.

The HPI is one of the chart sections payers commonly review when assessing medical necessity. The assessment is another. Together they tell a reader why the visit happened and what reasoning drove the plan.³

A single HPI often runs two to four sentences. Short does not mean shallow. A complete history of present illness example walks the chief complaint through the relevant descriptors and anchors the diagnostic shortlist.

What follows: three worked HPI examples, the eight elements behind them, the reasoning, the rules that hinge on the HPI, and customization for your practice.

What does a good history of present illness example look like?

A good HPI reads like a tight narrative paragraph. The most applicable descriptors are covered by a short clause or two. The history of present illness examples below show how the same OLDCARTS scaffold produces different paragraphs for cardiac, musculoskeletal, and behavioral-health complaints.

Example 1: Chest pain, 58-year-old patient.

Patient presents with substernal chest pressure that started 90 minutes ago while shoveling snow. The 7/10 pressure radiates to the left arm and feels like a heavy weight, with associated diaphoresis and shortness of breath. It has not changed with rest, and there are no prior episodes.

Example 2: Low back pain, 42-year-old patient.

Patient presents with dull, aching pain in the lumbar region that has been present for six weeks and gradually worsening. Pain is 4/10 at rest and 7/10 with prolonged sitting, and does not radiate. Standing briefly and ibuprofen ease the pain. The pain is worse in the morning for the first hour after waking.

Example 3: Anxiety follow-up, 31-year-old patient on sertraline 50 mg.

Patient returns four weeks after starting sertraline 50 mg for generalized anxiety. Background worry has dropped from a daily 8/10 to a 4/10 by week three, and sleep onset has improved from 90 minutes to 30 minutes. Patient denies nausea, sexual side effects, and suicidal ideation, and still avoids work meetings.

Each history of present illness example covers seven or eight OLDCARTS descriptors in three sentences or fewer. Different complaints lean on different descriptors. Chest pain leans on severity and radiation, back pain on onset and alleviating factors, and anxiety on side-effect screening and a measurable severity drop.

What should a complete HPI include?

The three examples above each pass the chief complaint through the same eight descriptors. The most widely taught version is OLDCARTS: Onset, Location, Duration, Character, Aggravating/alleviating factors, Radiation, Timing, and Severity.² A few elements may be N/A for a given complaint, but the relevant ones belong in the note.

The eight OLDCARTS descriptors:

• Onset. When the symptom first started. Specific is better ("two hours ago" or "after dinner Tuesday") than relative ("recent").
• Location. Where the symptom is. Pin to a body region or a specific structure.
• Duration. How long the symptom has been present, total. Timing (a separate element) covers the pattern.
• Character. What the symptom feels like (sharp, dull, pressing, burning). Use the patient's own words when they are clinically useful.
• Aggravating and alleviating factors. What makes the symptom worse and what makes it better.
• Radiation. Whether the symptom moves to another body region.
• Timing. Pattern of the symptom (constant, intermittent, worse in the morning, after meals).
• Severity. Use a 0–10 scale or impact-based language ("could not finish dinner").

The eight elements work whether the chief complaint is acute, chronic, or behavioral health-flavored. Not every visit requires all eight descriptors. Document the elements that are clinically relevant to the patient's presentation, and write the history of present illness example in plain language.

Why does the HPI matter for billing, diagnosis, and continuity?

A complete history of present illness example does three jobs at once. It supports documentation that underlies the billed E/M level and narrows the diagnostic shortlist before the exam. It also gives the next clinician enough context for hand-off care. A vague HPI weakens all three.

The HPI is one of the chart elements that supports E/M code selection. Under the 2021 CMS guidelines, E/M level is driven mostly by medical decision-making.³ A complete HPI still anchors the diagnostic story. A thin HPI ("patient here for follow-up") gives an auditor no way to defend the billed code.

The HPI is also where the diagnostic shortlist takes shape. Eight descriptors applied to a complaint like "chest pain" point a clinician toward an ACS workup or a costochondritis exam before the stethoscope comes out. The shortlist guides the physical exam that follows, the labs that get ordered, and what the assessment paragraph eventually says.

The HPI is also the section the next clinician reads first. A specialist, a covering provider, or a coder reconciling a claim relies on the HPI to compress the patient's story. The history of present illness example carries that load whenever the chart gets passed downstream.

The cost of a vague HPI compounds across the practice. Documentation time is one of the strongest pressure points clinicians describe in their day,⁸ and rework caused by ambiguous HPIs lands inside that pressure. Standardizing the history of present illness example through a shared template is a low-cost way to cut rework without trimming the encounter itself.

What documentation and compliance rules apply to the HPI?

Three layers of rules apply to the HPI in an outpatient chart. CMS office/outpatient E/M guidelines anchor billing for the visit. HIPAA and state medical boards govern how the data inside the HPI is stored, amended, and shared.

• CMS 2021 office/outpatient E/M guidelines. In 2021, CMS moved E/M coding for office and outpatient visits (CPT 99202–99215) away from counting history and exam bullets toward scoring medical decision-making complexity.³ A complete HPI still supports the diagnostic narrative, but it no longer drives the code by element count.
• AMA documentation standards. AMA guidance reinforces that documentation should reflect the actual encounter and support medically necessary services.⁷ A cloned or copy-forwarded history of present illness example that no longer matches the visit carries audit risk.
• HIPAA Privacy Rule (45 CFR 164.502-514). The HPI contains PHI by definition. The minimum necessary standard applies to disclosures for payment and healthcare operations (such as claims and audits), but not to disclosures for treatment, where clinicians can share what is needed for care.⁶
• HIPAA documentation retention is six years. 45 CFR 164.530(j) requires covered entities to keep HIPAA-related documentation (policies, signed authorizations, NPP acknowledgments) for at least six years.⁶ Medical record retention itself is governed by state law and CMS rules, with state requirements often longer, especially for pediatric records.
• Late entries appear as labeled addenda. Any change to the HPI after the note is signed should be a dated addendum, with the original entry unchanged.

Templates support compliance, they do not guarantee it. Frame an HPI template as part of a broader effort to standardize your clinical notes, with language like "designed with HIPAA and 2021 CMS E/M guidelines in mind". Have your compliance officer review the template before clinical use.

How do you customize an HPI template for your specialty?

Customization happens in three layers: by specialty, by EHR, and by who owns the template. Each layer touches a different part of the HPI workflow. Tight customization keeps the template usable without slowing the visit.

Adapt the history of present illness example to your specialty.

• Primary care HPIs lead with onset, location, and aggravating/alleviating factors across a wide complaint mix.
• Behavioral health HPIs lean on character, severity, and timing of psychiatric symptoms, plus a side-effect and SI screen on follow-ups.
• Physical therapy HPIs lead with location, severity, and aggravating/alleviating factors tied to functional movement.

Match the HPI template to your EHR. Most modern EHRs let you build the HPI as a smart phrase or "dot phrase" that pulls in OLDCARTS prompts. The Word or PDF template should map field-for-field to the EHR version, keeping the paper and digital templates in sync.

Plan for AI medical scribes inside the HPI. An AI medical scribe drafts the HPI from the visit conversation in the patient's own words and the clinician's clinical voice. The clinician reviews and edits before anything posts to the chart.

For the full chart context that holds the HPI, see the medical chart template guide. For a ranked breakdown by practice size and specialty, see the best AI medical scribes guide.

How Commure Scribe drafts the HPI inside your H&P template

Commure Scribe drafts the HPI directly from the visit conversation, in four steps. The scribe transcribes the visit and extracts symptom descriptors that map to OLDCARTS. It writes those descriptors into the clinician's voice and drops the paragraph into the HPI section of the H&P template.

The four-step move fixes the three HPI failure modes the rationale section named:

• A vague HPI gets sharper because the descriptors come from the patient's words, not from a copy-forwarded boilerplate.
• Hand-off reading improves because the HPI lands in the same OLDCARTS structure every visit.
• Audit defense holds because the diagnostic story is written at the time of care, not rebuilt at night.

The custom template builder lets the practice keep its existing H&P shell. It tells Commure Scribe which fields make up the HPI section, including any in-house variations on OLDCARTS. The scribe then writes a history of present illness example into that scaffold every visit.

Frequently asked questions

What is the difference between the chief complaint and the HPI?

The chief complaint is one short phrase, ideally in the patient's own words, that names the reason for the visit. The history of present illness example is the narrative paragraph that follows and walks through eight descriptors of that complaint. The chief complaint anchors the visit; the HPI builds the case for what to do about it.

What are the 8 elements of an HPI?

A history of present illness example covers eight OLDCARTS elements: Onset, Location, Duration, Character, Aggravating and alleviating factors, Radiation, Timing, and Severity. Each one captures a specific dimension of the chief complaint. A few may be N/A for a given visit, but every relevant element should appear in the note.

How does the HPI affect E/M billing under the 2021 CMS guidelines?

The 2021 CMS guidelines moved E/M coding away from counting history and exam bullets toward scoring medical decision-making complexity. The HPI no longer drives the code by element count. A complete history of present illness example still anchors the diagnostic narrative the auditor reads. A thin HPI gives the auditor no way to support the billed code.

How can a small independent practice standardize HPI documentation without a full IT team?

Start with a baseline H&P template that scaffolds the history of present illness example as an OLDCARTS multi-line area. Edit the template once to match your specialty, then paste the same scaffold into your EHR's smart-phrase builder. A single clinician or office manager can own updates with a yearly review.

Can an AI medical scribe draft the HPI from the visit conversation?

Yes. An AI medical scribe transcribes the visit and drafts the history of present illness example. The draft uses the patient's own words and the clinician's clinical voice, mapped to the OLDCARTS scaffold inside the template. The clinician reviews and edits before anything posts to the chart. See Commure Scribe features for the HPI drafting workflow.

Disclaimer

This article and the linked H&P template are for informational and educational purposes only. They do not constitute legal, medical, or professional advice, and do not guarantee compliance with any specific regulation.

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