Chief complaint
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
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]
| 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
References
- ^ http://www.usc.edu/health/uscp/compliance/tm6.html#6
- ^ Optometric Management
- ^ sBMJ | Taking a history: Introduction and the presenting complaint
- ^ http://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf
- ^ Nelson, E; Kirk, J; McHugo, G; Douglass, R; Ohler, J; Wasson, J; Zubkoff, M. (1987). "Chief complaint fatigue: a longitudinal study from the patient's perspective". Fam Pract Res J. 6 (4): 175–88. PMID 3455125.
{{cite journal}}: Cite has empty unknown parameter:|author-name-separator=(help); Unknown parameter|author-separator=ignored (help); Unknown parameter|month=ignored (help) - ^ Emergency Medicine
- ^ Graff, LG 4th; Robinson, D. (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.
{{cite journal}}: Cite has empty unknown parameter:|author-name-separator=(help); Unknown parameter|author-separator=ignored (help); Unknown parameter|month=ignored (help)CS1 maint: numeric names: authors list (link) - ^ Ackermann, RJ; Kemle, KA; Vogel, RL; Griffin, RC Jr (1998). "Emergency department use by nursing home residents". Ann Emerg Med. 31 (6): 749–57. doi:10.1016/S0196-0644(98)70235-5. PMID 9624316.
{{cite journal}}: Cite has empty unknown parameter:|author-name-separator=(help); Unknown parameter|author-separator=ignored (help); Unknown parameter|month=ignored (help) - ^ "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.
External links
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