I had the opportunity to research some information on History of Present Illness. Read below for what I found out!

HPI Notes 

1.    Chief Complaint

a.    Reason why the patient has come to see the doctor

b.    Don’t ask questions robotically

                                               i.        Smile and talk to the patient J

2.    History of Present Illness

a.    Gather details about chief complaint

                                               i.        Qualify and quantify

b.    Location

                                               i.        Where? What part of eye?

c.    Quality

                                               i.        Sharp or dull pain?

d.    Severity

                                               i.        Unbearable pain or mild?

e.    Duration

                                               i.        Suddenly or gradually?

f.     Timing

                                               i.        Constant or comes and goes?

g.    Context

                                               i.        What were you doing when it happened?

h.    Modifying Factors

                                               i.        Have you done anything to help?

i.     Signs

                                               i.        Noticed anything additional?

3.    Review of Symptoms

a.    Cardiovascular, vasucalar, respiratory, etc.

b.    Always record patients answer, otherwise it is taken like it was not asked

4.    Past Medical Histories

a.    Ask about eye surgeries

b.    Document these!

                                               i.        High blood pressure

                                             ii.        Diabetes 

5.    Medications

a.    Blood thinning medications

                                               i.        Ask, could lead to explanation for brain bleed etc.

b.    Review current Medications

                                               i.        See if any have stopped or changed

c.    Record over the counter medications

                                               i.        Vitamins and meds

d.    Compliance 

                                               i.        See if they have actually been takin medication

6.    Drug Allergies

a.    Record what patient is allergic to

                                               i.        Include reaction and whether it is severe or not

7.    Family History

a.    Always ask about these

                                               i.        Glaucoma, macular degeneration, retinal detachment, amblyopia, hypertension, diabetes and cataracts

8.    Social History

a.    Ask about alcohol, drugs, and tobacco

                                               i.        Can be VERY awkward

9.    Pertinent Questions

a.    Specific questions to type of visit

b.    Put in HPI answers to questions regarding the symptom

10.  HIPAA

a.    Health Insurance Portability and Accountability Act of 1996

                                               i.        Shred patient info, do not talk loud about patient, don’t leave files visible to others

11.  Triage

a.    Emergency Situation

                                               i.        Result from pain, redness, blurred vision

12.  Documentation

a.    Age, sex, and race

b.    Mood and orientation

13.  Questions to Ask Per Appointment

a.    Cataracts

                                               i.        Glare or blurry vision

                                             ii.        Have you had surgery?

b.    Glaucoma - New Patient

                                               i.        How long?

                                             ii.        Eye drops?

                                            iii.        Who diagnosed it?

c.    Glaucoma – Established Patient

                                               i.        Eye pain or redness?

                                             ii.        Using drops as instructed?

d.    Retina Problems

                                               i.        Family History?

                                             ii.        When have you noticed changes?

                                            iii.        Both eyes or one?

e.    Diabetic Exam

                                               i.        A1C Value?

                                             ii.        Fasting Blood Sugar Level?

                                            iii.        Well controlled?

f.     Droopy Eyelids

                                               i.        Any surgeries?

                                             ii.        Double Vision?

g.    Trauma

                                               i.        Wearing safety glasses?

                                             ii.        Occur on the job?

                                            iii.        Date and time?

                                            iv.        How did it happen?

h.    Contact Lenses

                                               i.        What kind?

                                             ii.        Bifocal?

                                            iii.        How many hours a day?

                                            iv.        Sleeping in lenses?

                                              v.        How many years have you been wearing them?

                                            vi.        Last time you wore them?

                                           vii.        Solutions you use?

In summary, when evaluating a patient, play the detective role. Figure out what their problem is and why they are experiencing it. Always ask the small details and input that information into the HPI. Above all, be friendly and maintain a certain level of professionalism.