Now let's move on to charting the chief complaint. So, as we begin to chart the chief complaint we must first determine why is the patient at your office?
We will use guided questions to extract specific information that will be useful for the doctor. But we must also be mindful that we create an environment that the patient feels comfortable to complain.
Now let's define the chief complaint. While it can be useful, remember it does not have to be in the patient's own words and it can be as little as 2 words. Oftentimes we find ourselves falling into a crutch of listing on the chart that there is no change. I challenge you to dig a little deeper. Ask questions, and again, be mindful of that environment you're creating for the patient.