This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
status
ACTIVE
Fully-Specified Name
component
Chief complaint+Reason for visit
property
Find = Finding
time
Pt = Point in time: To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements.
system
^Patient
scale
Nar = Narrative: Text narrative, such as the description of a microscopic part of a surgical papule test.
method
Additional Names
short name
Finding; Findings; H+P; H+P.HX; Narrative; P prime; Point in time; Random; Report
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