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.
A. Details of the chief complaint must be clearly documented in the health record.
B. Timing and intensity of complaints must be clearly documented.
C. Causation of the complaint must be documented including accident, injury, and etiology.
D. Services billed to the payor must be consistent with the patient's chief complaint and objective clinical findings.
Chief Complaint