Proper documentation of the chief complaint involves several steps:
1. Listen Actively: Allow the patient to describe their primary concern without interruption. 2. Use the Patient's Own Words: Document the chief complaint verbatim to capture the patient's perspective. 3. Ask Clarifying Questions: Ensure you understand the complaint fully by asking open-ended questions. 4. Be Concise: Keep the statement brief but informative.
Example: "Patient states, 'I have been experiencing severe chest pain for the past two hours.'"
