Chief complaint location

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Mon Jun 11, 2018 4:00 pm

We understand that the chief complaint is an element of the HPI, although is this the only location that the chief complaint can be determined? For example, if a chief complaint is documented in the Assessment and Plan, or exam would it be appropriate to use if this is the only location it was documented?
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Mon Jun 25, 2018 11:50 am

The only information we are given in the Documentation Guidelines about the chief complaint is:


The purpose of the chief complaint it to identify the reason the patient is being seen. While it is considered part of the history (not necessarily the HPI) because it is part of the information gathered thru the interview of the patient, as long as we can identify the reason for the visit it really doesn’t matter what heading the provider documented it under. What we do have to be cautious of is using the diagnosis on the problem as the chief complaint.

I hope this answers your question!

Your question has been answered by Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA
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