Chapter 2: Documenting a Chief Complaint: Part 1

Question 1

Every chart note should start with?

Answer 1

A chief complaint.

Question 2

What does documentation compliance require?

Answer 2

Clear and appropriate chief complaint recorded in the patient’s own words.

Question 3

How does the MA can ensure that the chief complaint is documented thoroughly?

Answer 3

By asking the patient to further describe the symptoms.

Question 4

What does the final statement regarding a chief complain may read as?

Answer 4

Patient complain of heart palpitations describes as “heart hammering in my chest” on and off x2 weeks. Denies any participating events. Admits increased used of caffeine. Denies radiation, dizziness, SOB, sweating, PMH, or other symptoms. No new meds or supplements.