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[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]
Example. A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight. The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
The PICO process (or framework) is a mnemonic used in evidence-based practice (and specifically evidence-based medicine) to frame and answer a clinical or health care related question, [1] though it is also argued that PICO "can be used universally for every scientific endeavour in any discipline with all study designs". [2]
The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the ...
The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.
The main purpose of a problem statement is to identify and explain the problem. [3] [4] Another function of the problem statement is as a communication device. [3] Before the project begins, stakeholders verify the problem and goals are accurately described in the problem statement. Once approved, the project reviews it.
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
Patients may exaggerate symptoms in order to make their situation seem worse, or they may under-report the severity or frequency of symptoms in order to minimize their problems. Patients might also simply be mistaken or misremember the material covered by the survey.