Chief Complaint

 

 HNS Policy

Details of complaint must be clearly documented in the healthcare record. 

 

Timing and intensity of complaints must be clearly documented. 

 

Causation of the complaint must be documented including accident, injury, and etiology.

 

Diagnoses reported in the healthcare record should be supported by the chief complaint/clinical exam findings.

 

Services provided and billed to the payor should be clearly related to the chief complaint/clinical exam findings. 

  

Chief Complaint is a concise statement describing the symptoms, problems, conditions, or other factors that are the reason for the encounter and is usually stated in the patient's own words.