Where in the medical note are the chief complaint (CC), history of present illness (HPI), and review of systems (ROS) typically listed?

Study for the Ophthalmic Scribe Certification. Get ready for your exam with our comprehensive materials including multiple choice questions with explanations and hints!

The chief complaint (CC), history of present illness (HPI), and review of systems (ROS) are typically listed in the subjective section of a medical note. This section is focused on the patient’s reported symptoms and experiences, reflecting their personal account of their health concerns.

The chief complaint captures the primary issue that brings the patient to seek care, while the history of present illness provides a detailed account of the circumstances surrounding the chief complaint, including its duration, severity, and associated symptoms. The review of systems is a systematic inquiry that gathers information about other bodily systems which may not have been directly addressed in the history but may be relevant to the patient’s overall health status.

In contrast, the objective section includes findings from physical examinations and diagnostic tests, focusing on measurable and observable data. The assessment section contains the clinician's interpretation and diagnosis based on the information gathered, and the plan section outlines the proposed management and treatment strategies. Thus, the subjective section is the appropriate location for the CC, HPI, and ROS, as it encapsulates the patient’s narrative and subjective experiences.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy