Starting the Patient Encounter
Every patient encounter begins with two fundamental elements: the chief complaint (CC) and the history of present illness (HPI). These form the foundation of the clinical record and guide everything that follows. As a CPO, accurately capturing this information is one of your most important responsibilities.
Chief Complaint
The chief complaint is the patient's primary reason for coming in, recorded in their own words. It is a direct quote or close paraphrase of what the patient tells you, not a clinical interpretation. If a patient says, "My right eye has been red and itchy for three days," that is your chief complaint.
Common CC documentation mistakes to avoid:
- Interpreting instead of recording: writing "allergic conjunctivitis" instead of "red, itchy eye for three days"
- Recording only one complaint when the patient mentions several
- Omitting the duration when the patient provides it
History of Present Illness (HPI)
The HPI expands on the chief complaint by systematically exploring every dimension of the presenting problem. The standard framework covers eight elements, often remembered by the mnemonic OLDCARTS or similar systems:
- Onset: When did it start? Was it sudden or gradual?
- Location: Which eye? Where on the eye or eyelid?
- Duration: How long has it been present?
- Character: What does it feel like? Sharp, dull, burning, foreign body sensation?
- Alleviating factors: What makes it better? Rest? Drops? Removing contacts?
- Relieving/aggravating factors: What makes it worse? Bright light? Reading?
- Timing: Is it constant or intermittent? Worse at certain times of day?
- Severity: How bad is it on a scale of 1 to 10? Is it worsening?
Associated symptoms are equally important. Always ask whether the patient has noticed any vision changes, discharge, pain, redness, or light sensitivity related to the complaint.
Connecting CC and HPI to the Exam
The CC and HPI directly inform what pre-testing is most relevant. A patient presenting with "sudden floaters and flashes" triggers a different protocol than one presenting for an annual exam. Understanding what each complaint may indicate helps you anticipate what the physician will need and streamline pre-testing appropriately.
Documentation Standards
Record the CC and HPI clearly, legibly, and completely. Use standard abbreviations (OD = right eye, OS = left eye, OU = both eyes). Avoid ambiguous language. Date and initial your entries per your practice's protocol. If using an EHR, complete all relevant fields rather than leaving the HPI blank.
Key Takeaways
- Chief complaint = patient's own words describing their primary reason for the visit
- HPI systematically explores onset, location, duration, character, timing, severity, and associated symptoms
- Never record a diagnosis as the chief complaint
- Open-ended questions first, focused follow-ups to complete the HPI
- The CC and HPI guide appropriate pre-testing and save physician time