Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Date of Visit:
Chief Complaint (CC):
Use the patient’s own words, quoted directly whenever possible, to capture the main reason for their visit.
This could be a single sentence or a brief description of their symptoms or concerns.
Example 1: “I’ve had a sore throat for the past 3 days and it feels like I have sandpaper in my throat.”
Example 2: “I’m concerned about a sharp pain in my lower right abdomen that started yesterday.”
Additional Information (Optional):
In some cases, you may need to add clarifying information or a brief elaboration on the CC, particularly if the patient’s description is vague.
This should be done in your own words, not the patient’s.
Onset: Briefly mention when the symptoms began (e.g., “for the past 3 days”).
Severity: If applicable, include a brief description of the symptom severity (e.g., “mild cough”, “severe pain”).
Context: In some situations, adding context to the CC can be helpful (e.g., “developed after eating shellfish”, “worsens with activity”).
Example: “Chief Complaint: Sharp pain in lower right abdomen that started yesterday evening and worsens with coughing.”
Note:
The Chief Complaint is a crucial element of the medical record, providing a starting point for the physician’s assessment and guiding the direction of the encounter.
Strive for accuracy and clarity in capturing the patient’s main concern.