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2. CHIEF COMPLAINTS
The concept of a chief complaint is important in medicine.⚕️ It is
a statement of the reason that a patient seeks medical ⚕️care.
Medical🏥 and nursing🏥 schools🎓 teach future clinicians🩺 to begin their
verbal🔊📢🎙️ presentations of patient cases📑 with a statement of the chief
complaint.
They teach them to record 📝the chief complaint
using the patient's 🗣️🔊📢words and to avoid🚫⛔ replacing the patient's
words🗣️🔊📢 with their diagnostic interpretation⛑️🩺. It is considered bad ⛔🚫
form to proffer a diagnostic impression⛑️🩺 in a chief complaint. 1
The reasons for this practice are myriad. One reason is that other clinicians🩺 such as consultants🩺 and supervisory clinicians 🩺
in academic medical centers 🏥read a patient's chart🗂️📑 like detectives: 🔍🕵️🕵️♂️⚕️They wish to form an independent diagnostic⛑️🩺 impression.
They are interested in knowing 'just the facts.'
Handbook of Biosurveillance 333
ISBN 0-12-369378-0
Elsevier Inc.
To have A Medical⚕️ License 📃and Be Competent in Medicine⛑️⚕️🩺 You must have The Patient's 🗣️💭History and Chief Complaints🗣️💭🔊📢 In Own Words, History of Present Illness, OLD CARTS 7 7️⃣aspects of a Symptom, Review of Systems, Pertinent Positives, ➕Negatives, Past Medical History, Medications 💊➖Physical Examination, Labs,🩸🧪 Imaging,, 🩻Tests, and Differential Diagnosis.Without This You have No⛔ Medical License🦆⛔🩺 No Scientific ⚕️Approaches and Lack Medical ⚕️🩺 Competence. ( See Bates History and Physical Examination Textbook 📖) used to Train Physicians.🩺⚕️Medical Records Keeping Systems (ie EHR's Electronic Health Records🖥️ /Paper Have Placeholders for This System which Reflects This Organization. Like The Chief Complaint 🗣️💭🔊📢 In Own Words
An Electronic Health ⚕️Record🖥️📑 (EHR) is an electronic🖥️ version of a patients medical⛑️ history, that is maintained by the provider over time, and may include all of the key administrative clinical⚕️ data relevant to that persons care under a particular provider, including demographics, progress notes,📄 problems, medications💊, vital signs🚧,(Pulse,❤️ Blood🩸 Pressure, Respiratory 🌬️🫁Rate, Body Temperature 🌡️🔥🥵🥶 Fever
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