Presenting problem

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The Chief Complaint formally known as CC in the medical field, or termed Presenting Complaint (PC) in the UK, forms the second step of medical history taking, and is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medical encounter.[1] The patient's initial comments to a physician, nurse, or other health care professional help form the differential diagnosis.

In some instances, the nature of a patient's chief complaint may determine whether or not services are covered by medical or vision insurance.[2]

Medical students are advised to use open-ended questions in order to obtain the presenting complaint.[3]

Other terms sometimes used include Reason for Encounter (RFE), Presenting Problem, Problem on admission and Reason for Presenting.[citation needed]

Analyzing for the chief complaint involves assessment using the acronym SOCRATES, OPQRST.

Prevalence[edit]

The collection of chief complaint data may be useful in addressing public health issues.[4] Certain complaints are more common in certain settings and among certain populations. Fatigue has been reported as one of the ten most common reasons for seeing a physician.[5] In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints.[6] The most common complaint in ERs has been reported to be abdominal pain.[7] Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms, and falls are the most commonly reported.[8]

CMS required history elements[9]
Type of history CC HPI ROS Past, family, and/or social
Problem focused Required Brief N/A N/A
Expanded problem focused Required Brief Problem pertinent N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete

See also[edit]

References[edit]

  1. ^ http://www.usc.edu/health/uscp/compliance/tm6.html#6
  2. ^ Optometric Management
  3. ^ sBMJ | Taking a history: Introduction and the presenting complaint
  4. ^ http://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf
  5. ^ Nelson, E, Kirk, J, McHugo, G, Douglass, R, Ohler, J, Wasson, J, Zubkoff, M. (Summer 1987). "Chief complaint fatigue: a longitudinal study from the patient's perspective". Fam Pract Res J. 6 (4): 175–88. PMID 3455125. 
  6. ^ Emergency Medicine
  7. ^ Graff, LG 4th, Robinson, D. (Feb 2001). "Abdominal pain and emergency department evaluation". Emerg Med Clin North Am. 19 (1): 123–36. doi:10.1016/S0733-8627(05)70171-1. PMID 11214394. 
  8. ^ Ackermann, RJ, Kemle, KA, Vogel, RL, Griffin, RC Jr (Jun 1998). "Emergency department use by nursing home residents". Annals of Emergency Medicine 31 (6): 749–57. doi:10.1016/S0196-0644(98)70235-5. PMID 9624316. 
  9. ^ "www.cms.gov". Retrieved 2011-02-27. 

External links[edit]