Presenting problem

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 if 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.

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]

CMS required history elements[9]
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. ↑ "VI. Evaluation and Management (E/M) Services". Compliance Training Manual. www.usc.edu. Archived from the original on 2001-05-03.
  2. ↑ "coding q & a - Medical Vs. Vision Insurance". Optometric Management. July 1, 2004. Archived from the original on December 25, 2016.
  3. ↑ Shah, Nayankumar (2005). "Taking a history: Introduction and the presenting complaint". Student BMJ. 13: 309–52. doi:10.1136/sbmj.0509314 (inactive 2018-09-21). Archived from the original on 2017-09-05.
  4. ↑ "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" (PDF). Centers for Disease Control and Prevention. May 27, 2003. Archived from the original (PDF) on 2006-10-23.
  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". Family Practice Research Journal. 6 (4): 175–88. PMID 3455125.
  6. ↑ "Differentiating Chest Pain". Emergency Medicine. Archived from the original on 2011-07-30.
  7. ↑ Graff, Louis G.; Robinson, Dave (2001). "Abdominal Pain and Emergency Department Evaluation". Emergency Medicine Clinics of North America. 19 (1): 123–36. doi:10.1016/S0733-8627(05)70171-1. PMID 11214394.
  8. ↑ Ackermann, Richard J; Kemle, Kathy A; Vogel, Robert L; Griffin, Ralph C (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.
  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.
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