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 …

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.

What should chief complaint include?

A chief complaint is a concise statement of the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter.

What is a patient’s chief complaint?

What is the Chief Complaint (CC)? The CC is a brief statement that describes the symptom, problem, diagnosis, or other reason for the patient encounter. The CC is usually stated in the patient’s own words: “I have an upset stomach, my knees ache, and I need refills on my pain pills.”

How do I file a chief complaint in ophthalmology?

The patient history begins with the chief complaint. It should detail the primary reason(s) the patient scheduled the examination. Ideally, it should be recorded in the patient’s own words. The chief complaint also suggests what tests you’ll need to perform and the possible CPT code to use for the encounter.

Is chief complaint a diagnosis?

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 present illness?

The CC is the reason why the patient is there. The HPI details the CC. Although the CC directs the line of questioning in the HPI and the Review of Systems (ROS), the extent of history obtained should not be more than is medically necessary to evaluate the patient.

Why do we write down 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 considered past medical history?

In a medical encounter, a past medical history (abbreviated PMH), is the total sum of a patient’s health status prior to the presenting problem.

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.