MAR 12, 2019
Language for Chief Complaint
Question: We recently obtained a satellite office that uses “vision stable” as the chief complaint for established glaucoma patients. Is this acceptable?
Answer: Although not an appropriate chief complaint, it could be an element to the HPI. As the chief complaint conveys the reason for the exam and helps determine what elements of the exam are medically necessary to perform, typically the chief complaint is “follow-up for glaucoma evaluation OU.”
Learn more about E&M in the 1-hour Online Course E/M Documentation Guidelines for all Specialties.