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  • Patient History Form Name: Chief Complaint:

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PATIENT HISTORY FORM Name: Chief Complaint: (reason for visit) Family History: (list all medical problems in your immediate family) Past Medical History: (circle all personal medical problems) High.

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The History portion contains the chronology of what is wrong with the patient - often the "what is wrong with the patient" is called the "chief complaint" and is often abbreviated "CC" in the History documentation in the medical record.

A chief complaint is a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care. A triage nurse or registration clerk records a patient's chief complaint at the very beginning of the medical care process (Figure 23.1 ).

The “Magnificent Seven” Location: Where is the pain now? ... Onset: How did the pain start? ... Duration: How long has the pain been present? ... Severity: How bad is the pain now? ... Quality: What type of pain is it?

A chief complaint should comprise a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return or other factors that establish the reason for the encounter in the patient's own words (e.g., aching joints, rheumatoid arthritis, gout, fatigue, etc.).

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.

A chief complaint should comprise a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return or other factors that establish the reason for the encounter in the patient's own words (e.g., aching joints, rheumatoid arthritis, gout, fatigue, etc.).

A chief complaint is a concise statement in English or other natural language of the symptoms that caused a patient to seek medical care. A triage nurse or registration clerk records a patient's chief complaint at the very beginning of the medical care process (Figure 23.1 ).

Open clinical notes Be clear and succinct. Directly and respectfully address concerns. Use supportive language. Include patients in the note-writing process. Encourage patients to read their notes. Ask for and use feedback. Be familiar with how to amend notes.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232