CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition,
diagnosis, physician recommended return, or other factor that is the reason for
the encounter.
DG: The medical record should clearly reflect the chief complaint
HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient's
present illness from the first sign and/or symptom or from the previous
encounter to the present. It includes the following elements:
- location,
- quality,
- severity,
- duration,
- timing,
- context,
- modifying factors, and
- associated signs and symptoms.
Brief and extended HPIs are distinguished by the amount of detail needed to
accurately characterize the clinical problem(s).
A brief HPI consists of one to three elements of the HPI.
