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.
Do you need a chief complaint for every patient?
Yes, you need a chief complaint in every patient’s record, but “no complaints” is perfectly valid. I usually write “no visual or asthenopic complaint” on the chief complaint line, and then list four pertinent negatives for completeness sake (usually something like “no tearing, itching, burning, or blurred vision”).
How to write a chief complaint?
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
How is a patient's chief complaint documented?
The patient's chief complaint is recorded at the time of registration and transmitted immediately to a health department via a HL7 message router. When the patient is discharged from the ED and admitted to the hospital, a professional coder reads the patient's ED chart and assigns ICD codes for billing purposes.
How to fill out chief complaint?
- Ask the patient to expand on the chief complaint or complaints. ...
- Get specific numbers for things like how long the patient has had the symptoms or how much pain, on a scale of 0 to 10, the patient is experiencing.
- Record, as accurately as you can, what the patient tells you. ...
What are some examples of chief complaints?
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 ...
What is the purpose of the chief complaint?
The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance.
How do you find the chief complaint of a patient?
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 asking the patient what brings them to be seen ?and what major symptoms or problems they are experiencing?
What is the most common chief complaint?
Sore throat, skin rash, abdominal pain, earache, and backache were the five most common complaints (302 per 1,000 patients.) These complaints and 19 other problems were responsible for 822 patient visits per 1,000 in a study of 2,272 consecutive new patient visits.
What is a CPT complaint?
CPT defines the 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.”. Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services. An easily identifiable chief complaint is the ...
Do you need a chief complaint for preventive medicine?
Preventive medicine services (CPT® 99381-99387) do not require a chief complaint. Because a preventive medicine service is not problem-oriented, you should not diagnose it, as such. Instead, match preventive medicine codes with an appropriate ICD-9-CM code to support the services provided (e.g., V70.0 Routine general medical examination ...
What is the chief complaint in a doctor's appointment?
The doctor uses what they identify as the chief complaint as the priority of the appointment and then focuses their line of questioning and physical exam on it. Remember, they have a specific format for the appointment so they will be asking questions within a framework to work toward a diagnosis and/or treatment.
What is a CPT complaint?
CPT defines the 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.”. Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services. When you call for an appointment, get ...
What is the most important component of a medical interview?
One of the most important components of the medical interview is the chief complaint . The chief complaint is used by the doctor to structure the appointment and informs what questions he asks and the physical exam that is needed. the primary symptom that a patient states as the reason for seeking medical care.
Can you talk about only one symptom?
Realistically, you can only talk about and address one or maybe a couple of issues maximum. Prior to the appointment, think about what is the most important thing you would like addressed. It doesn't necessarily mean only one symptom, it can be a group of symptoms but it should be one issue.
What is a CPT complaint?
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, Self-limited or minor, Low severity, Moderate severity and High severity. The CC can be problem-oriented or preventative.
What is a CC in CPT?
The CC can be problem-oriented or preventative. The CC is related to the Nature of the Presenting Problem or “disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter,” according to the CPT® manual. The definitions for the CC and the Presenting Problem overlap.
