What should be documented as the chief concern of a patient?

The chief concern of a patient is documented as the Chief Complaint (CC). This is the primary issue or symptom that the patient presents with while seeking medical care. Accurately recording the chief complaint is crucial as it sets the focus for the entire clinical evaluation and guides the healthcare provider in determining the appropriate course of action.

The chief complaint is typically stated in the patient’s own words and reflects their immediate health concern, which can help direct the clinical assessment and any necessary interventions. It is foundational to formulating a diagnosis and creating a treatment plan tailored to the patient’s needs.

Other options like PMHx (Past Medical History), SHx (Social History), and PHx (Past History) provide important contextual information about the patient's background and previous health issues, but they do not represent the immediate concern that brought the patient to the emergency department. Each of these histories contributes to the overall assessment but does not substitute the need for a clear and documented chief complaint.