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https://www.aapc.com/blog/42585-chief-complaint-required/
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
https://medical-dictionary.thefreedictionary.com/chief+complaint
chief complaint (CC) a subjective statement made by a patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care. It is used most often in a health history.
https://www.aapc.com/blog/31589-the-chief-complaint-a-vital-documentation-element/
The CPT® codebook defines the Chief Complaint (CC) as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” CPT® recognizes five levels of presenting problems: Minimal,...
https://5.insynchcs.com/Help/Source/HTML/how_to_record_chief_complaints.htm
Chief Complaint is a statement made by a patient describing the most significant or serious symptoms, or signs of illness, that caused the person to seek healthcare. Following the chief complaint, complete details of the illness are recorded; that is referred to as History of Present Illness (HPI).
http://www.whatismedicalinsurancebilling.org/2012/09/what-is-chief-complaint-and-history-of.html
CHIEF COMPLAINT (CC) The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. DG: The medical record should clearly reflect the chief complaint HISTORY OF PRESENT ILLNESS (HPI)
https://namas13.wildapricot.org/resources/Pictures/NAMAS%20Weekly%20Tip%20081916%20Chief%20Complaint.pdf
preventative encounters, the noted chief complaint should be "annual exam" or "preventive encounter". The chief complaint is a clear, concise statement that describes the reason for the patient encounter. Guidelines indicate that the chief complaint should be documented using the patient's own words. However, this is also within
https://www.emuniversity.com/ChiefComplaint.html
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”) .
https://quizlet.com/368361964/chapter-38-the-medical-record-flash-cards/
an expansion of the chief complaint and includes a full description of patient's current illness from the time of onset list five examples of information included in the past medical history. major illness, childhood disease, accidents, immunizations and allergies
https://quizlet.com/224030065/final-for-dr-p-chapter-38-medical-record-flash-cards/
Creation of a medical record, Storage of a medical record, Storage of a medical record, Editing of a medical record, retrieval of a medical record. In a source-oriented record, a radiology report is filed under which of the following chart dividers.
https://en.wikipedia.org/wiki/History_of_the_present_illness
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (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).
https://www.urmc.rochester.edu/medialibraries/urmcmedia/compliance-office/education-tools/compliance/documents/emdocumentationtips4-08.pdf
Document your own HPI Reference a nurse, clinical tech, or medical student’s HPI . Past Medical, Family, Social History (PFSH) DO DON’T Give pertinent details from each history category • “Patient has previous left ankle fracture.” “Family history of type 2 diabetes.” …
https://www.wikihow.com/Write-a-Good-Medical-History
Dec 30, 2019 · This is where you ask about any symptoms the patient is experiencing that are related to the chief complaint. Associated symptoms are often the key to making a correct diagnosis. The patient may not recognize that associated symptoms are related to the chief complaint and may not even view them as symptoms.
https://www.sharecare.com/health/managing-your-health-care/what-is-chief-complaint
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.
https://www.icd10monitor.com/auditing-issues-uncovered-in-physician-documentation-part-ii-2
May 14, 2018 · A chief complaint is a statement, typically in the patient’s own words: “my knee hurts,” for example, or “I have chest pain.” On occasion, the reason for the visit is follow-up, but if the record only states “patient here for follow-up,” this is an incomplete chief complaint, and the auditor may not even continue with the record and negate its value altogether.
https://en.wikipedia.org/wiki/SOAP_note
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. There can be multiple CC's, but identifying the most significant one is vital to make a proper diagnosis.
http://samples.jbpub.com/9781449652722/9781449645106_CH02_037_064.pdf
The medical record can be dissected into five primary components, including the medical history (often known as the history and physicalor , h&p ), laboratory and 1,2diagnostic test results, the problem list, clinical notes, and treatment notes.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf
CHIEF COMPLAINT (CC) The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. DG: The medical record should clearly reflect the chief complaint.
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