Certified Medical Assistant (CMA AAMA)Clinical Workflow and Patient IntakeEasy
During patient intake, a medical assistant documents the reason the patient states for the visit, using the patient's own words in quotation marks. This documentation is known as the:
- Apresent illness history
- Bchief complaint
- Csocial history
- Dreview of systems
Show answer & explanationAnswer & explanation
Correct answer: B. chief complaint
The chief complaint is the patient's own description, ideally quoted verbatim, of the primary reason for the visit. It differs from the history of present illness, which expands on the complaint with details like onset and duration.
Why the other options are wrong
- A. History of present illness elaborates on the chief complaint but is not the verbatim statement itself.
- C. Social history covers lifestyle factors like occupation and habits.
- D. Review of systems is a systematic check of body systems, not the presenting statement.
Chief Complaint
A brief statement, ideally in the patient's own words, describing the primary reason for the office visit.
- Recorded in patient's own words when possible
- Often placed in quotation marks in the chart
- Distinct from the history of present illness
Memory trick: 'Chief in quotes, complaint devotes.'