Capture the HPI across every OLDCARTS element — and flag what's missing

Someone hands over what a patient reported — a spoken account, rough intake notes, a dictation — and asks for it captured as the history of present illness (HPI). Left to itself, the model does two things wrong. It covers whichever symptom details happen to be salient and silently skips the rest, so the write-up is uneven — rich on character and onset, blank on timing and radiation. And worse, when a detail is missing it invents a plausible one: it writes "pain radiates to the left arm" or "severity 7/10" because that is what a chest-pain note usually says, not because the patient said it. A fabricated HPI detail is a clinical liability — it can steer a differential or get copied forward as if the patient reported it.

The discipline is two rules applied together:

1. Sweep all eight elements every time — the OLDCARTS set below — so the capture is complete and

evenly covered, not just the parts that stood out.

1. Never invent an element the source did not give. If the account is silent on an element, say

so plainly ("radiation: not documented") rather than filling it with a typical value. Absence is information; a guess dressed as a report is not.

The eight elements (OLDCARTS)

Address each one. The letters are a memory aid — the write-up itself can be a narrative paragraph or a labeled list, but every element must be accounted for, present or explicitly absent.

• O — Onset. When and how it began: the moment or rough time it started, and what the patient

was doing at the time (at rest, during exertion, woke them from sleep, gradual over days).

• L — Location. Where the symptom is — the body region or site. For a non-localized symptom

(fatigue, fever), note that it has no single location rather than leaving it blank.

• D — Duration. How long each episode lasts and whether the symptom is constant or comes and

goes. Distinct from onset: onset is when it first started, duration is how long it lasts.

• C — Character. What the symptom feels like in the patient's own terms — sharp, dull, burning,

cramping, throbbing, pressure-like, tingling.

• A — Aggravating / relieving factors. What makes it worse and what makes it better — position,

movement, food, rest, medication, breathing.

• R — Radiation. Whether the symptom spreads or moves from its origin to somewhere else, and to

where. If the patient did not mention spread, mark it absent — do not add a textbook radiation.

• T — Timing. The temporal pattern over the course of the illness: time of day, frequency,

whether it is worsening, improving, or stable, and any relationship to events or activities.

• S — Severity. How bad it is — a 0–10 rating if the patient gave one, or their own words

("worst ever," "mild," "enough to stop work"). Never assign a number the patient did not state.

The flag-if-missing rule

For every element the source did not supply, name the element and mark it not provided. Preferred phrasings: "not documented," "not reported," "the patient did not specify." Do not paper over the gap with prose that reads as if the detail were reported.

Say the intake note is: "Throbbing right-sided headache since last night, worse in bright light, no nausea." That gives onset/duration (since last night), location (right side of the head), character (throbbing), and an aggravating factor (bright light). It is silent on radiation, timing pattern, and severity. The correct capture records the four given elements and then states: radiation — not documented; timing — not documented; severity — not documented. It does not write "radiates to the back, 6/10, worse at night," none of which the patient said.

Two consequences of the rule:

• Distinguish a negative from a gap. "No radiation" (the patient was asked and said it doesn't

spread) is a reported finding. "Radiation not documented" (never established) is a gap. Only write a negative when the source actually gives one; otherwise it is a gap.

• Do not manufacture precision. If the patient said "a while ago," keep it as "a while ago" —

do not convert it to "three days ago." Vague-but-real beats precise-but-invented.

Scope

Capture the HPI only. Do not add a differential diagnosis, an assessment, orders, or codes — those are separate steps. If the handoff includes exam findings or vitals, they belong to the objective record, not the HPI; leave them out of the symptom capture unless they are part of what the patient reported.