Presenting problem

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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.[citation needed]

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. http://www.usc.edu/health/uscp/compliance/tm6.html#6
  2. http://www.optometric.com/article.aspx?article=71722[full citation needed]
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  4. http://www.cdc.gov/PHIN/architecture/implementation_guides/Healthcare%20Related/PHIN_Healthcare_Encounter_Chief_Complaint_v231.pdf
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  6. http://www.emedmag.com/html/pre/cov/covers/021504.asp Emergency Medicine[full citation needed]
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External links