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Bobs Presenting Complaint What is the problem? How are you feeling? When did your problem/symptoms begin? What were you doing when the symptoms began? What makes the problem or symptoms worse? What makes the problem or symptoms better? How long have you had these symptoms? Where does it hurt?
How do you describe a chief complaint?
A chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter.
How do you identify a patients chief complaint?
A chief complaint is a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care. A triage nurse or registration clerk records a patients chief complaint at the very beginning of the medical care process (Figure 23.1 ).
How do you obtain a chief complaint?
When obtaining the chief complaint, medical students are advised to use open-ended questions. Once the presenting problem is elucidated, a history of present illness can be done using acronyms such as SOCRATES or OPQRST to further analyze the severity, onset and nature of the presenting problem.
What is an example of a chief complaint?
If you are seeing your primary care doctor the chief complaint might be, annual physical exam, or shortness of breath or chest pain or even I just dont feel good. In orthopedics, most of the time when the surgeon lists the chief complaint they describe which joint you have pain in.
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How do you write a chief complaint statement?
Introductory Statement with Chief Complaint: is a brief statement explaining the reason the patient presented to the hospital or ambulatory setting (if appropriate). It includes the patients age, gender, most pertinent past medical history and major symptoms(s) and duration.
How do you document a patients chief complaint?
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 patients words.
What is the correct documentation of a patient chief complaint?
The CC should be a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patients own words.
Related links
Chief Complaint (CC)
Properly reference patient questionnaire or SMH 761 form. Include pertinent findings. PFSH per patient questionnaire. Reviewed and confirmed. Details.
by S Karagounis 2020 Cited by 3 Chief complaints tend to be inconsistent and challenging to organize or analyze. The free text format gives the flexibility to the writer of the
Adult Medical Record Review Tool -- Primary Care Provider
May 30, 2014 15. Treatment plans are consistent with diagnoses. □ Addresses each chief complaint (subjective/objective) and clinical finding with a plan of
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