Presenting complaint
Also called Chief complaint, PC
The presenting complaint is the main problem that brought the patient in, recorded in a short phrase and ideally in the patient's own words.
Why it matters in a workup
The presenting complaint frames the whole assessment. Exertional chest pain for six weeks sets up a different history and differential from chest pain.
Keep it short and specific. The detail belongs in the history of presenting complaint that follows it.
Example
John Doe, 58: chest tightness on stairs and walking uphill for six weeks.
Put it into practice
- Write it in a few words, with the duration
- Use the patient's words where they add meaning
- Record a second complaint separately rather than merging them
Frequently asked questions
What if the patient has several complaints?
List each one and address them in order of importance. Merging them into one phrase hides which one the plan is for.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- History of presenting complaintThe history of presenting complaint is the detailed story of the main problem: onset, character, timing, triggers, relieving factors and associated symptoms.
- WorkupA workup is the process of assessing a patient's problem: gathering sources, taking the history, examining, investigating and writing the assessment.