Which of the following is not needed when describing a patients 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.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?

It is not the part of the history that deals with chronic medical problems or family history of disease.It focuses the physicians attention on what the priority should be in the evaluation of the patient. It helps to direct  the additional history taking and it helps to lead to the appropriate physical exam of the pertinent organ systems of the patient that are relevant to the problem.

Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.

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]


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

  • Identified patient
  • Medical history


  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.

  • MedEd at Loyola ipm/comphx1/sld003.htm

Retrieved from "https://en.wikipedia.org/w/index.php?title=Chief_complaint&oldid=1062451183"

The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive.  Each type of history includes some or all of the following elements:

Key Components

  • Chief complaint (CC)
  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family and/or social history (PFSH)

Contributory Factors

  • Counseling
  • Coordination of care
  • Nature of presenting problem
  • Time

Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors.  The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the

presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the history table must be met. A chief

complaint is indicated at all levels.

History of Present Illness (HPI)

Review of Symptoms (ROS)

Risk of Complications and/or Morbidity and Mortality

Type of Decision Making






Problem Pertinent


Low Complexity

Extended Problem



Moderate Complexity

Extended Problem



High Complexities

Chief Complaint (CC): A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record.

History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements:

  • Location: What is the location of the pain?
  • Quality: Include a description of the quality of the symptom (i.e.  sharp pain)
  • Severity: Degree of pain for example can be described on a scale of 1 - 10
  • Duration: How long have you had the pain
  • Timing:  Describe when you have pain for example pain with exertion or pain in evening
  • Context: What is the patient doing when the pain begins
  • Modifying Factors: What makes the pain better or worse for example aspirin helps
  • Associated Signs and Symptoms: Physician based on assessment may ask about other sensations or feelings for example – do you experience pain while exercising
  • Two Levels of HPI:
    • Brief HPI: Requires one to three HPI elements (see above list)
    • Extended HPI: Requires four HPI elements or the status of three chronic problems (see 1997 guidelines for status of chronic conditions)