The Patient Complaints section captures the patient's own words about what is wrong, plus the details that put their complaint in context.
What to fill in
- Chief Complaint — what the patient says is wrong, in their own words when possible.
- Anatomic Location — where on the body the problem is.
- Organ System — which body system is involved.
- Duration — how long the patient has had the complaint.
- Onset — gradual or sudden.
- Work-related — was the complaint caused by work?
Quoting the patient
For chief complaint, the gold standard is to use the patient's own words. "Chest pain" is fine. "Worst headache of my life" is better — those are the patient's exact words and they tell the receiving physician something a clinical term cannot.
An example
You ask the patient what is wrong. She says "I can't catch my breath, it started about an hour ago after I climbed the stairs." In Patient Complaints you put Chief Complaint as "Shortness of breath, started 1 hour ago after climbing stairs," Anatomic Location as Chest, Organ System as Respiratory, Duration as 1 hour, and Onset as Gradual. The receiving nurse reads it and immediately understands the picture.