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Notes & formats

HPI (History of Present Illness)

Structured account of the patient's current symptoms — the heart of the Subjective section.

HPI captures the patient's present illness in a standardised way: onset, location, duration, character, aggravating/relieving factors, related symptoms, severity. It's the most clinically important part of a SOAP note and the part where ambient scribes either shine or quietly invent content.

The hallucination question for HPI is: *did the patient actually say this, or did the model fill in what's statistically likely for a visit of this kind?* That's the single best place to spot-check a scribe.

See also

  • SOAP noteStandard four-part clinical note: Subjective, Objective, Assessment, Plan.
  • AI hallucinationWhen an AI model writes something confidently into a note that was never said.