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 patient’s chief complaint at the very beginning of the medical care process (Figure 23.1 ).
What is chief complaint example?
A chief complaint is a statement, typically in the patient’s own words: “my knee hurts ,” for example, or “I have chest pain.” On occasion, the reason for the visit is follow-up, but if the record only states “patient here for follow-up,” this is an incomplete chief complaint, and the auditor may not even continue with ...
What does the chief complaint include?
The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter . In some instances, the nature of a patient’s chief complaint may determine if services are covered by health insurance.
What is the purpose of a chief complaint?
Chief complaints—also commonly referred to as presenting problems, clinical syndromes, or reasons for visit—are important because the chief complaint often guides diagnostic decision making and care . It is also a vital data element collected by regional and state public health systems to monitor for disease outbreaks.
What is the most common chief complaint?
Sore throat, skin rash, abdominal pain, earache, and backache were the five most common complaints (302 per 1,000 patients.)
How do you write a good chief complaint?
A chief complaint should comprise a concise statement describing the symptom, problem , condition, diagnosis, physician-recommended return or other factors that establish the reason for the encounter in the patient’s own words (e.g., aching joints, rheumatoid arthritis, gout, fatigue, etc.).
Is chief complaint required?
Patient History Requirements. Chief complaint. ... Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).
Can a chief complaint be more than one thing?
From a medical practice perspective, there is only one chief complaint per visit , with all other issues documented through the review of systems.
What is a presenting complaint in safeguarding?
The Presenting complaints or issues section carries information about the complaints or issues experienced by the patient . ... The description of the health problems and issues experienced by the patient resulting in their attendance.
Is medication refill a valid chief complaint?
At times Compliance has observed the CC documented as “follow up” or “med refill.” These are not appropriate chief complaints as they provide no clue as to the presenting problem. A more appropriate CC would include the reason for follow-up or the problem(s) associated with the need for medication refills.
What is medical complaint?
(kəm-plānt′) a. A bodily disorder or disease; a malady or ailment. b. The symptom or distress about which a patient seeks medical assistance .
What is required for a 99204?
A 99214 requires a detailed history and physical exam, and a 99204 requires a comprehensive history and physical exam . ... For a 99204, the physical exam must cover at least 18 bullets from at least nine systems or body areas. A 99214 requires at least 12 bullets from at least two systems or body areas.
What is a routine check up?
When you visit your doctor for a routine checkup, the nurse will take you to the exam room and will typically: check your blood pressure and other vital signs . verify your health history, medications, allergies, and lifestyle choices in your electronic medical record .
What is a presenting condition?
A presenting problem is an initial symptom that causes a person to seek professional help from a doctor, therapist, or another mental health provider . While it’s normal to experience up and downs in your mental health, you may find that you need additional support for a particular symptom or set of symptoms.
What questions should I ask a chief complaint?
- Location: Where is the pain now? ...
- Onset: How did the pain start? ...
- Duration: How long has the pain been present? ...
- Severity: How bad is the pain now? ...
- Quality: What type of pain is it?
What are the most common conditions treated in the emergency department?
- Headaches. The number one and the most common ER visit is due to headaches.
- Foreign Objects in the Body. ...
- Skin Infections. ...
- Back Pain. ...
- Contusions and Cuts. ...
- Upper Respiratory Infections. ...
- Broken Bones and Sprains. ...
- Toothaches. ...
