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The patient's chief complaint, or CC, is a very brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization. [1] There can be multiple CC's, but identifying the most significant one is vital to make a proper diagnosis.
[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance. [3]
chief complaint (CC) "abdominal pain" Can also include a more detailed line, such as "30 yo F c/o abdominal pain", though this can be redundant to the HPI. Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a symptom from a patient. history of present illness (HPI)
Physical examinations are performed in most healthcare encounters. For example, a physical examination is performed when a patient visits complaining of flu-like symptoms. These diagnostic examinations usually focus on the patient's chief complaint. [citation needed]
He designed a set of standardized protocols to triage patients via the telephone and thus improve the emergency response system. Protocols were first alphabetized by chief complaint that included key questions to ask the caller, pre-arrival instructions, and dispatch priorities. After many revisions, these simple cards have evolved into MPDS.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Previous presence of the symptom (same chief complaint) Allergies (drugs, foods, chemicals, dust, etc.) Medicines (any drugs the patient used) Hospitalization for any illness in the past; Urinary changes (especially if diabetic or elderly) Gastrointestinal complaints (diet changes, bowel movements, etc.) Sleep pattern (waking up/going to sleep ...
This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading. [9] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing. Region and ...