AAMA CMA Practice Question

The chief complaint is a concise statement of the patient's reason for seeking medical attention. It should be recorded exactly as the patient expresses it (often placed in quotation marks) to preserve the subjective nature of the information and avoid introducing the clinician's interpretation. Doing so ensures accuracy and directs the focus of the history of present illness and subsequent evaluation. Options that substitute medical terminology, list physical-exam findings, or provide the clinician's diagnostic impression do not meet documentation standards.