Chief complaint

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.[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]

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.[citation needed]

  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. S2CID 155837706. 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.