Summary to date 13Feb2008:
Hmm - varied views.
I'll take a risk here and try to summarise - *# Reason for encounter Encounter is completely different from presenting Presenting (or chief) complaintComplaint.
- "Reason for Encounter" is the reason for attendance - seeking emergency help/Pre-employment medical/consultation/therapy etc
- "Presenting Complaint" is a description of symptoms or issues by the patient.
- There may be multiple symptoms so better to name it Presenting complaint (and enable as many as needed) rather than Chief complaint (which implies one main one). For example:
- Better to name it complaint rather than symptoms, so as not to limit it to only symptomatology but open it to issues eg want to stop smoking, lose weight, relationship problems (ie issues).
- Currently the concept "Presenting Complaint" is reflected by an archetype "Story" - this archetype has been named to deliberately 'de-medicalise' it, so that it can be used for a broader range of purposes and contexts than doctors seeing patients, including Personal Health Records, Counselling etc etc. It has been renamed as "Presenting Complaint" in templates used for a medical purpose eg a consultation record.
- In practice:
- "Story" can enable free text recording of the patient's story including nested clusters to describe each symptom in detail if needed.
- Presenting complaint #1 with symptom details eg cough
- Presenting complaint #2 with symptoms details eg fever
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