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OKLAHOMA DEPARTMENT OF CORRECTIONS NURSING PRACTICE PROTOCOLSMSRM 140117.01.10.2 (R4/19)HEAD TRAUMA Subjective Data: Allergies: ___ Chief complaint: ___ ___ Date of injury:___ Time of injury:___ Activity
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Begin by asking the patient to describe their main reason for coming in.
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Use open-ended questions to gather as much information as possible.
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Document the complaint in the patient's own words.
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Be sure to include any pertinent symptoms or details.
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Ask follow-up questions to clarify any unclear information.
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Record the chief complaint accurately and concisely in the patient's medical record.

Who needs chief complaint?

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Chief complaint is needed by healthcare providers such as doctors, nurses, and other medical professionals to understand the primary reason for a patient's visit.
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Chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter with a healthcare professional.
Chief complaint is typically filled out by the patient or their guardian, and recorded by the healthcare professional during the medical encounter.
To fill out chief complaint, the patient or their guardian should provide a brief description of the reason for their visit to the healthcare professional.
The purpose of chief complaint is to help the healthcare professional quickly identify the primary reason for the patient's visit, in order to provide appropriate care and treatment.
Chief complaint should include a concise description of the symptom, problem, or condition that brought the patient to seek medical attention.
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