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 patient’s words.
What is an example of a chief complaint?
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
Who gives 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 patient’s chief complaint at the very beginning of the medical care process (Figure 23.1 ).
Why do we write the chief complaint?
The purpose of writing a good chief complaint is to strengthen the understanding and analysis of the disease, to strengthen the training of language skills, and to pay more attention and care.
What is a chief complaint in case history?
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 difference between chief complaint and presenting problem?
Terminology. The presenting complaint in EDs refers to a professional interpretation of the symptoms or condition that made the patient seek emergency care. Presenting complaint is a term more established in Europe and Canada and its counterpart term in the U.S. is chief complaint (CC).
What are the characteristics of chief complaint?
These “magnificent seven” characteristics are listed here.
The “Magnificent Seven”
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?
Is chief complaint required?
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. A CC is required for all levels of service.
Is chief complaint required 2021?
The chief complaint will continue to be required for each E/M visit. The history and exam have been eliminated for code selection, and only need to be performed and documented for the visit when medically necessary and clinically appropriate.
Does chief complaint have to be in patients own words?
Chief complaint.
The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC.
What is a chief complaint Social Work?
A Chief complaint is the medical term used to describe the primary problem of the patient that led the patient to seek medical attention and of which they are most concerned.
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.) These complaints and 19 other problems were responsible for 822 patient visits per 1,000 in a study of 2,272 consecutive new patient visits.
