Revision as of 01:21, 4 November 2018 editMtsuha (talk | contribs)20 edits Linked "history of present illness" to the appropriate wikipedia pageTag: Visual edit← Previous edit |
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{{Short description|Principal reason for a person seeking professional assistance}} |
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The '''chief complaint''', formally known as '''CC''' in the medical field, or termed '''presenting complaint''' ('''PC''') in Europe and Canada, forms the second step of ] taking. It is sometimes also referred to as '''reason for encounter''' ('''RFE'''), '''presenting problem''', '''problem on admission''' or '''reason for presenting'''.{{citation needed|date=November 2018}}<ref>{{Cite journal|last=Malmström|first=Tomi|last2=Huuskonen|first2=Olli|last3=Torkki|first3=Paulus|last4=Malmström|first4=Raija|date=2012|title=Structured classification for ED presenting complaints – from free text field-based approach to ICPC-2 ED application|url=https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-20-76|journal=Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine|language=En|volume=20|issue=1|pages=76|doi=10.1186/1757-7241-20-76|issn=1757-7241|pmc=PMC3564900|pmid=23176447}}</ref> The chief complaint is a concise statement describing the ], problem, ], ], ]-recommended return, or other reason for a medical |
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The '''chief complaint''', formally known as '''CC''' in the medical field, or termed '''presenting complaint''' ('''PC''') in Europe and Canada, forms the second step of ] taking. It is sometimes also referred to as '''reason for encounter''' ('''RFE'''), '''presenting problem''', '''problem on admission''' or '''reason for presenting'''.{{citation needed|date=November 2018}}<ref>{{cite journal | vauthors = Malmström T, Huuskonen O, Torkki P, Malmström R | title = Structured classification for ED presenting complaints - from free text field-based approach to ICPC-2 ED application | journal = Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | volume = 20 | issue = 1 | pages = 76 | date = November 2012 | pmid = 23176447 | pmc = 3564900 | doi = 10.1186/1757-7241-20-76 | doi-access = free }}</ref> The chief complaint is a concise statement describing the ], problem, ], ], ]-recommended return, or other reason for a medical |
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encounter.<ref>{{cite book|url=http://www.usc.edu/health/uscp/compliance/tm6.html#6|chapter=VI. Evaluation and Management (E/M) Services|title=Compliance Training Manual|publisher=www.usc.edu|archiveurl=https://web.archive.org/web/20010503032321/http://www.usc.edu/health/uscp/compliance/tm6.html|archivedate=2001-05-03}}</ref> In some instances, the nature of a patient's chief complaint may determine if services are covered by ] or ].<ref>{{cite web|url=http://www.optometricmanagement.com/issues/2004/july-2004/coding-q-a-medical-vs-vision-insurance|title=coding q & a - Medical Vs. Vision Insurance|publisher=Optometric Management|date=July 1, 2004|deadurl=no|archiveurl=https://web.archive.org/web/20161225083149/http://www.optometricmanagement.com/issues/2004/july-2004/coding-q-a-medical-vs-vision-insurance|archivedate=December 25, 2016|df=}}</ref> |
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encounter.<ref>{{cite book|chapter-url=http://www.usc.edu/health/uscp/compliance/tm6.html#6|chapter=VI. Evaluation and Management (E/M) Services|title=Compliance Training Manual|publisher=www.usc.edu|archive-url=https://web.archive.org/web/20010503032321/http://www.usc.edu/health/uscp/compliance/tm6.html|archive-date=2001-05-03}}</ref> In some instances, the nature of a patient's chief complaint may determine if services are covered by ].<ref>{{cite web|url=http://www.optometricmanagement.com/issues/2004/july-2004/coding-q-a-medical-vs-vision-insurance|title=coding q & a - Medical Vs. Vision Insurance|publisher=Optometric Management|date=July 1, 2004|url-status=live|archive-url=https://web.archive.org/web/20161225083149/http://www.optometricmanagement.com/issues/2004/july-2004/coding-q-a-medical-vs-vision-insurance|archive-date=December 25, 2016}}</ref> |
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When obtaining the chief complaint, ]s are advised to use open-ended questions.<ref>{{cite journal |doi=10.1136/sbmj.0509314 |first1=Nayankumar |last1=Shah |year=2005 |title=Taking a history: Introduction and the presenting complaint |journal=Student BMJ |volume=13 |pages=309–52 |url=http://student.bmj.com/student/view-article.html?id=sbmj0509314 |deadurl=no |archiveurl=https://web.archive.org/web/20170905135041/http://student.bmj.com/student/view-article.html?id=sbmj0509314 |archivedate=2017-09-05 |df= |doi-broken-date=2018-09-21 }}</ref> Once the presenting problem is elucidated, a ] can be done using acronyms such as ] or ] to further analyze the severity, onset and nature of the presenting problem. The patient's initial comments to a physician, ], or other ] are important for formulating ]. |
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When obtaining the chief complaint, ]s are advised to use open-ended questions.<ref>{{cite journal |doi=10.1136/sbmj.0509314 |first1=Nayankumar |last1=Shah | name-list-style = vanc |year=2005 |title=Taking a history: Introduction and the presenting complaint |journal=Student BMJ |volume=13 |pages=309–52 |s2cid=155837706 |url=http://student.bmj.com/student/view-article.html?id=sbmj0509314 |url-status=dead |archive-url=https://web.archive.org/web/20170905135041/http://student.bmj.com/student/view-article.html?id=sbmj0509314 |archive-date=2017-09-05 }}</ref> <ref>{{cite book |last1=Bickley |first1=Lynn | name-list-style = vanc |title=Bates' Guide to Physical Examination and History Taking |date=2017 |publisher=Wolters Kluwer |location=Philadelphia |isbn=9781469893419 |edition=12th }}</ref> Once the presenting problem is elucidated, a ] can be done using acronyms such as ] or ] to further analyze the severity, onset and nature of the presenting problem. The patient's initial comments to a physician, ], or other ]s are important for formulating ].{{cn|date=December 2021}} |
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==Prevalence== |
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==Prevalence== |
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The collection of chief complaint data may be useful in addressing ] issues.<ref>{{cite web|url=https://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf|title=Implementation Guide for Transmission of Patient Chief Complaint as Public Health Information using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol|date=May 27, 2003|publisher=Centers for Disease Control and Prevention|archiveurl=https://web.archive.org/web/20061023095850/http://www.cdc.gov/phin/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf|archivedate=2006-10-23}}</ref> Certain complaints are more common in certain settings and among certain populations. ] has been reported as one of the ten most common reasons for seeing a physician.<ref>{{cite journal |pmid=3455125 |year=1987 |author1=Nelson |first1=E |title=Chief complaint fatigue: A longitudinal study from the patient's perspective |journal=Family Practice Research Journal |volume=6 |issue=4 |pages=175–88 |last2=Kirk |first2=J |last3=McHugo |first3=G |last4=Douglass |first4=R |last5=Ohler |first5=J |last6=Wasson |first6=J |last7=Zubkoff |first7=M }}</ref> In ] settings, such as ]s, reports of ] are among the most common chief complaints.<ref>{{cite web|url=http://www.emedmag.com/html/pre/cov/covers/021504.asp|publisher=Emergency Medicine|title=Differentiating Chest Pain|archiveurl=https://web.archive.org/web/20110730094756/http://www.emedmag.com/html/pre/cov/covers/021504.asp|archivedate=2011-07-30}}</ref> The most common complaint in ERs has been reported to be ].<ref>{{cite journal |doi=10.1016/S0733-8627(05)70171-1 |pmid=11214394 |title=Abdominal Pain and Emergency Department Evaluation |journal=Emergency Medicine Clinics of North America |volume=19 |issue=1 |pages=123–36 |year=2001 |last1=Graff |first1=Louis G. |last2=Robinson |first2=Dave }}</ref> Among ] residents seeking treatment at ERs, ] symptoms, altered mental status, ]s, and ] are the most commonly reported.<ref>{{cite journal |doi=10.1016/S0196-0644(98)70235-5 |pmid=9624316 |title=Emergency Department Use by Nursing Home Residents |journal=Annals of Emergency Medicine |volume=31 |issue=6 |pages=749–57 |year=1998 |last1=Ackermann |first1=Richard J |last2=Kemle |first2=Kathy A |last3=Vogel |first3=Robert L |last4=Griffin |first4=Ralph C }}</ref> |
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The collection of chief complaint data may be useful in addressing ] issues.<ref>{{cite web|url=https://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf|title=Implementation Guide for Transmission of Patient Chief Complaint as Public Health Information using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol|date=May 27, 2003|publisher=Centers for Disease Control and Prevention|archive-url=https://web.archive.org/web/20061023095850/http://www.cdc.gov/phin/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf|archive-date=2006-10-23}}</ref> Certain complaints are more common in certain settings and among certain populations. ] has been reported as one of the ten most common reasons for seeing a physician.<ref>{{cite journal | vauthors = Nelson E, Kirk J, McHugo G, Douglass R, Ohler J, Wasson J, Zubkoff M | title = Chief complaint fatigue: a longitudinal study from the patient's perspective | journal = Family Practice Research Journal | volume = 6 | issue = 4 | pages = 175–88 | year = 1987 | pmid = 3455125 }}</ref> In ] settings, such as ]s, reports of ] are among the most common chief complaints.<ref>{{cite web | first1 = Nasir | last1 = Hussain | first2 = Bernard | last2 = Karnath | name-list-style = vanc | url = http://www.emedmag.com/html/pre/cov/covers/021504.asp |publisher=Emergency Medicine |title=Differentiating Chest Pain |archive-url = https://web.archive.org/web/20110730094756/http://www.emedmag.com/html/pre/cov/covers/021504.asp |archive-date=2011-07-30 | url-status = dead }}</ref> The most common complaint in ERs has been reported to be ].<ref>{{cite journal | vauthors = Graff LG, Robinson D | title = Abdominal pain and emergency department evaluation | journal = Emergency Medicine Clinics of North America | volume = 19 | issue = 1 | pages = 123–36 | date = February 2001 | pmid = 11214394 | doi = 10.1016/S0733-8627(05)70171-1 }}</ref> Among ] residents seeking treatment at ERs, ] symptoms, altered mental status, ]s, and ] are the most commonly reported.<ref>{{cite journal | vauthors = Ackermann RJ, Kemle KA, Vogel RL, Griffin RC | title = Emergency department use by nursing home residents | journal = Annals of Emergency Medicine | volume = 31 | issue = 6 | pages = 749–57 | date = June 1998 | pmid = 9624316 | doi = 10.1016/S0196-0644(98)70235-5 }}</ref> |
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{{CMS Medical history types|align=right}} |
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{{CMS Medical history types|align=right}} |
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==See also== |
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== See also == |
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* ] |
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==References== |
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== References == |
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{{reflist|2}} |
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{{reflist|2}} |
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==External links== |
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== External links == |
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* {{LoyolaMedEd|ipm/comphx1/sld003.htm}} |
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* {{LoyolaMedEd|ipm/comphx1/sld003.htm}} |
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