Section[ 4 - ED Arrival & First Assessment Data
PART OF THE CHIEF COMPLAINT GROUP (4.06 AND 4.07)*
Patient’s reason for seeking care or attention, expressed in terms as close as possible to those used by patient or responsible informant.
Data collected on the patient’s chief complaint are pivotal to the clinical process and provide an important resource for measuring and evaluating health care services. The chief complaint figures prominently in triage decision making and is a key determinant of the direction and extent of history taking, physical examination, and diagnostic testing in the ED. When ED data on chief complaint are aggregated and linked with process, diagnosis, and financial data, they take on added value for clinical and epidemiologic research, practitioner training, quality management, and health care administration and finance.
Chief complaints encompass more than reports of symptoms or complaints. A chief complaint may also be a request for:
— a diagnostic, screening, or preventive procedure.
— treatment or compliance with a practitioner’s instructions to seek a specific treatment, procedure, or medication.
— test results.
— an examination required by a third-party.
— a referral, such as follow-up initiated from this ED or elsewhere.
— intervention for a stated diagnosis or disease.
Although data describing the chief complaint are routinely and often repetitively recorded during a single ED visit, the data generally are not classified, coded, and stored in a form that facilitates aggregate analysis. Several established systems are candidates for classifying and coding ED chief complaints, but modifications or adaptations are likely to be needed for routine ED use. Among the candidate systems are the International Classification of Primary Care (ICPC), Reason for Visit Classification and Coding Manual (RVC), Systematized Nomenclature of Human and Veterinary Medicine — SNOMED International, Read Codes Version 3, and the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM). In the interim, text descriptions or local codes can be used.
Data Type (and Field Length)
CE — coded element (200).
Yes; if there is more than one chief complaint, the Chief Complaint Group repeats.
*The Chief Complaint Group includes data elements 4.06 and 4.07. A single iteration of this group is used to report each chief complaint.
Component 1 is the chief complaint code. Component 2 is the chief complaint descriptor. Component 3 is the coding system identifier.
Components 4–6 can be used for an alternate code, descriptor, and coding system identifier.
For example, to encode headache using the International Classification of Primary
Care (ICP): Component 1 = N01
Component 2 = Headache
Component 3 = ICP
Text data also can be entered without an accompanying code, as follows: Component 1 = ""
Component 2 = Headache
If the chief complaint is unknown, enter data in the following manner: Component 1 = Unknown
Data Standards or Guidelines
ICPC (Lamberts and Wood, 1987), RVC (National Center for Health Statistics, 1994), SNOMED International (Cote et al., 1993), Read Codes Version 3: A User Led Terminology (O’Neill et al., 1995), and ICD-9-CM ( U.S. Department of Health and Human Services, 1995).