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Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services. An easily identifiable chief complaint is the first step in establishing medical necessity for services rendered.Author: John Verhovshek
chief complaint The principal reason for a person seeking medical attention; CCs include acute abdomen, colicky pain, crushing chest pain, hip fracture, etc. See Complaint, Minor complaint. chief com·plaint (CC) (chēf kŏm-plānt')
ONE CHIEF COMPLAINT of residents is the lack of professionalism and cleanliness exhibited by maintenance technicians.
A Chief complaint is the medical term used to describe the primary problem of the patient that led the patient to seek medical attention and of which they are most concerned. The chief complaint is obtained by the Physician in the initial part of the visit when the medical history is being taken.It will be elicited by...
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As a result, the chief complaint cannot just be anywhere on the record. “It must either be listed separately or in the HPI.” Key: The guidelines do not come out and say ‘it must be at the top of the note,’ however the guidelines are very clear that the chief complaint should not be implied but stated clearly.
Many physicians don't realize that a chief complaint is required for every type of encounter. It may be a somatic complaint from the patient (e.g., “headache” or “shortness of breath”) or it may be a statement from the physician which defines the purpose for the visit (e.g., “follow-up for hypertension”) .
Jul 22, 2014 · The chief complaint is the focus of the exam. If the patient has several complaints, document them in order of highest to lowest medical risk. For example, consider the elements of the exam performed when the patient complains of red eyelids that itch, and compare them to the elements of the exam performed when the second complaint is that the vision in the left eye has become …
Aug 18, 2006 · In some cases, the nurse or the medical assistant can write the chief complaint on the top of the form before the doctor sees the patient, suggests Parks. Then the doctor can come in and initial the chief complaint at the start of the visit.
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The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.
Evaluation and Management Documentation Tips URMC – Compliance Office – 4/08 1 . Chief Complaint (CC) DO DON’T . Specify reason for the visit • “Patient presents for follow-up evaluation of ankle sprain.” Fail to specify reason for visit • “Patient presents for follow-up.” Specify who requested a consult and why • “
entry of the chart as the “chief complaint,” and indicate “no changes” or “new complaint” if appropriate. If this is an off-cycle visit, you must treat the patient as if it were a new encounter. In other words, there must be an acute complaint to satisfy the medical necessity for the service.
"The Chief Complaint is a Concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for
Mar 24, 2017 · A chief complaint based handbook for diagnosing and treating patients in the ER How would you like to walk in the ER confident that you knew what to do, no matter what comes through the door? The Chief Complaint uses an algorithmic approach to over 50 of the most common complaints encountered in the ER.4.6/5(45)
Chief complaints and ICD codes are used ubiquitously in medical care in the United States in both the civilian and military healthcare systems. Medicare and other third party payers require these data for billing and claims. As a result, the healthcare industry has built significant electronic infrastruc-
Chief complaints, the primary symptoms reported by a patient seeking treatment, often guide diagnostic decision-making and care in the ED. Aggregated chief complaint data are also used by regional and state-level public health systems for syndromic surveillance.
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