Presenting problem

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.[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 medical or vision insurance.[3]

When obtaining the chief complaint, medical students are advised to use open-ended questions.[4] [5] Once the presenting problem is elucidated, a history of present illness can be done using acronyms such as SOCRATES or OPQRST to further analyze the severity, onset and nature of the presenting problem. The patient's initial comments to a physician, nurse, or other health care professionals are important for formulating differential diagnoses.

Prevalence

The collection of chief complaint data may be useful in addressing public health issues.[6] 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.[7] In acute care settings, such as emergency rooms, reports of chest pain are among the most common chief complaints.[8] The most common complaint in ERs has been reported to be abdominal pain.[9] Among nursing home residents seeking treatment at ERs, respiratory symptoms, altered mental status, gastrointestinal symptoms, and falls are the most commonly reported.[10]

CMS required history elements[11]
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. Malmström T, Huuskonen O, Torkki P, Malmström R (November 2012). "Structured classification for ED presenting complaints - from free text field-based approach to ICPC-2 ED application". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 20 (1): 76. doi:10.1186/1757-7241-20-76. PMC 3564900. PMID 23176447.
  2. "VI. Evaluation and Management (E/M) Services". Compliance Training Manual. www.usc.edu. Archived from the original on 2001-05-03.
  3. "coding q & a - Medical Vs. Vision Insurance". Optometric Management. July 1, 2004. Archived from the original on December 25, 2016.
  4. Shah N (2005). "Taking a history: Introduction and the presenting complaint". Student BMJ. 13: 309–52. doi:10.1136/sbmj.0509314. Archived from the original on 2017-09-05.
  5. Bickley L (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Philadelphia: Wolters Kluwer. ISBN 9781469893419.
  6. "Implementation Guide for Transmission of Patient Chief Complaint as Public Health Information using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol" (PDF). Centers for Disease Control and Prevention. May 27, 2003. Archived from the original (PDF) on 2006-10-23.
  7. Nelson E, Kirk J, McHugo G, Douglass R, Ohler J, Wasson J, Zubkoff M (1987). "Chief complaint fatigue: a longitudinal study from the patient's perspective". Family Practice Research Journal. 6 (4): 175–88. PMID 3455125.
  8. Hussain N, Karnath B. "Differentiating Chest Pain". Emergency Medicine. Archived from the original on 2011-07-30.
  9. Graff LG, Robinson D (February 2001). "Abdominal pain and emergency department evaluation". Emergency Medicine Clinics of North America. 19 (1): 123–36. doi:10.1016/S0733-8627(05)70171-1. PMID 11214394.
  10. Ackermann RJ, Kemle KA, Vogel RL, Griffin RC (June 1998). "Emergency department use by nursing home residents". Annals of Emergency Medicine. 31 (6): 749–57. doi:10.1016/S0196-0644(98)70235-5. PMID 9624316.
  11. "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.
This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.