Presenting Complaint

This page doesn't have a description of the 'Presenting Complaint' field - it just dives right into details. Proposing we add an opening blurb to be consistent with the pages for other sections/fields.

This section is where the nurse enters the reason for a patient’s visit.

Complaint text entered will drive the search parameters of the CEDIS Complaint Smart Search feature.

It is mandatory to enter a complaint in at least one of the complaint fields:

• Patient’s Stated Complaint field: The patient’s complaint in the patient’s own words
  and/or
• Nurse Assessed Complaint field: If clinically appropriate, a nurse may also enter the patient complaint using the nurse’s own words. 
  Examples of when it may be clinically appropriate for a nurse to enter their own assessment: A patient is unconscious or unable to state their own complaint; a complaint other than the one stated by the patient is observed e.g., a patient may state they have a headache, while the nurse observes significant head injury. The nurse’s clinical description adds value or clarity to diagnosis.

Important: To improve the accuracy of the CEDIS Complaint Smart Search results, follow the guidelines below.

• Keep complaints focused, limited to 2 to 3 relevant keywords and use commas to separate different health concerns.
• Avoid using slashes or dashes.
• Use commas to separate different health concerns; text in between commas is treated as one search term i.e. abdominal pain, head trauma.
• If patient expresses multiple complaints, use your clinical judgement to enter the most acute presenting complaint.
• Examples: Patient states “my blood pressure is high, I have stomach pains, vomiting, and sore ribs from coughing”. The nurse can enter “high blood pressure, abdominal pain” as the most acute presenting complaints.