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==Prevalence== ==Prevalence==
The collection of chief complaint data may be useful in addressing ] issues.<ref>http://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf</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 | last1 = Nelson | first1 = E | last2 = Kirk | first2 = J | last3 = McHugo | first3 = G | last4 = Douglass | first4 = R | last5 = Ohler | first5 = J | last6 = Wasson | first6 = J | last7 = Zubkoff | first7 = M. | author-separator =, | author-name-separator= | year = 1987 | month = Summer | title = Chief complaint fatigue: a longitudinal study from the patient's perspective | url = | journal = Fam Pract Res J. | volume = 6 | issue = 4| pages = 175–88 | pmid = 3455125 }}</ref> In ] settings, such as ]s, reports of ] are among the most common chief complaints.<ref></ref> The most common complaint in ERs has been reported to be ].<ref>{{cite journal | doi = 10.1016/S0733-8627(05)70171-1 | last1 = Graff | first1 = LG 4th| last2 = Robinson | first2 = D. | author-separator =, | author-name-separator= | year = 2001 | month = Feb | title = Abdominal pain and emergency department evaluation | url = http://cat.inist.fr/?aModele=afficheN&cpsidt=917754 | journal = Emerg Med Clin North Am. | volume = 19 | issue = 1| pages = 123–36 | pmid = 11214394 }}</ref> Among ] residents seeking treatment at ERs, ] symptoms, altered mental status, ] symptoms, and ] are the most commonly reported.<ref>{{cite journal | doi = 10.1016/S0196-0644(98)70235-5 | last1 = Ackermann | first1 = RJ | last2 = Kemle | first2 = KA | last3 = Vogel | first3 = RL | last4 = Griffin | first4 = RC Jr | author-separator =, | author-name-separator= | year = 1998 | month = Jun | title = Emergency department use by nursing home residents | url = | journal = Ann Emerg Med. | volume = 31 | issue = 6| pages = 749–57 | pmid = 9624316 }}</ref> The collection of chief complaint data may be useful in addressing ] issues.<ref>http://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf</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 | last1 = Nelson | first1 = E | last2 = Kirk | first2 = J | last3 = McHugo | first3 = G | last4 = Douglass | first4 = R | last5 = Ohler | first5 = J | last6 = Wasson | first6 = J | last7 = Zubkoff | first7 = M. | author-separator =, | author-name-separator= | year = 1987 | month = Summer | title = Chief complaint fatigue: a longitudinal study from the patient's perspective | url = | journal = Fam Pract Res J. | volume = 6 | issue = 4| pages = 175–88 | pmid = 3455125 }}</ref> In ] settings, such as ]s, reports of ] are among the most common chief complaints.<ref></ref> The most common complaint in ERs has been reported to be ].<ref>{{cite journal | doi = 10.1016/S0733-8627(05)70171-1 | last1 = Graff | first1 = LG 4th| last2 = Robinson | first2 = D. | author-separator =, | author-name-separator= | year = 2001 | month = Feb | title = Abdominal pain and emergency department evaluation | url = http://cat.inist.fr/?aModele=afficheN&cpsidt=917754 | journal = Emerg Med Clin North Am. | volume = 19 | issue = 1| pages = 123–36 | pmid = 11214394 }}</ref> Among ] residents seeking treatment at ERs, ] symptoms, altered mental status, ] symptoms, and ] are the most commonly reported.<ref>{{cite journal | doi = 10.1016/S0196-0644(98)70235-5 | last1 = Ackermann | first1 = RJ | last2 = Kemle | first2 = KA | last3 = Vogel | first3 = RL | last4 = Griffin | first4 = RC Jr | author-separator =, | author-name-separator= | year = 1998 | month = Jun | title = Emergency department use by nursing home residents | url = | journal = Annals of Emergency Medicine | volume = 31 | issue = 6| pages = 749–57 | pmid = 9624316 }}</ref>


{{CMS Medical history types|align=right}} {{CMS Medical history types|align=right}}

Revision as of 03:31, 22 October 2013

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. 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.

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

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

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. 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. In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints. The most common complaint in ERs has been reported to be abdominal pain. Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms, and falls are the most commonly reported.

CMS required history elements
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

  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. (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)
  6. Emergency Medicine
  7. 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)
  8. Ackermann, RJ; Kemle, KA; Vogel, RL; Griffin, RC Jr (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. {{cite journal}}: Cite has empty unknown parameter: |author-name-separator= (help); Unknown parameter |author-separator= ignored (help); Unknown parameter |month= ignored (help)
  9. "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

Medical examination and history taking
Medical history
Physical examination
General/IPPA
Vital signs
HEENT
Respiratory
Cardiovascular
Abdominal
Musculoskeletal
Neurological
Neonatal
Gynecological
Sports
Assessment and plan


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