Certified Electronic Health Records Specialist (CEHRS) Practice Exam

What is defined as a verbal account made by the patient describing their problem?

1. Primary diagnosis

2. Chief complaint

3. Medical history

4. Patient assessment

The correct answer is: Chief complaint

The chief complaint refers to the specific issue or concern that a patient expresses during a medical visit. It is often the main reason for seeking medical attention and is typically recorded in the patient's medical record at the beginning of their visit or appointment. This verbal account captures the patient's perspective on their health issue and aids healthcare providers in formulating a diagnosis and treatment plan. In contrast, the primary diagnosis involves the physician's determined medical condition after evaluation, representing a clinical judgement rather than the patient's personal account. The medical history encompasses a comprehensive record of the patient's past health, including previous illnesses, treatments, and family medical history, which may inform the context of the chief complaint. The patient assessment includes examinations and evaluations conducted by the healthcare provider to understand the patient's condition further. However, none of these terms focus specifically on the patient’s verbal description of their immediate concern, which is why the chief complaint is the most appropriate answer.