Wiki Outpatient Reason for Visit/Chief Complaint

[tamstrnd]

In Outpatient documentation for coding, would you include the Chief Complaint along with the Reason for Visit in the documentation, or would the Reason for Visit be enough as a Chief Complaint so as not to be redundant?

I greatly appreciate your time and help!

Thank you!

Tammy

 

[SharonCollachi]

We don't have both sections in our documentation, but I could see how some people might have different answers to those two sections, like this:

1. Reason for visit: slipped and fell on steps and has new pain.
2. Chief Complaint: pain in back and legs.

Our documentation would say: new pain in back and legs, patient slipped and fell on steps.