Reason for encounter or Chief complaint

We have a decision to make. When people come to hospital a doctor will usually record the "Chief complaint" or "Presenting complaint". In primary care the "Reason for encounter" is recorded. As these are simple meta-observations and are best suited to be evaluations - no date information, no qualifiers - the point is to keep the data very clean.
The question is - should these be different archetypes or the same archetype with different labels for purpose. There is no doubt that their scope is different when we think of inpatient presentation compared with primary care - but it is possible to think of almost every situation in the continuum so that they do merge.
We could have a label for the node that allowed the choice of Reason for encounter OR Chief complaint OR Presenting complaint - and leave the terminology binding to the template. The advantage is that in every language we would have up to three conventions.
Retrieving this data from different situations would be simplified - one place to look. We could even use an item_single so the concept could not be extended. This would ensure it was used for summary data.What do others think?

Sam Heard (17 Dec 2007)

  • Sergio (18 Dec 2007)
    In our environment, either primary care or hospital setting, we use "motivo de consulta" which would translate as chief complaint. I must confess I can't see why the scope is different (the patient is in pain or has a symptom that makes him go to the primary care unit or ER) but this is my point of view only. I think that it would serve our purposes best to have one archetype with different label, the main objective is the same, to register what motivated the patient to seek help in the first place, I think different archetypes might lead to duplicate information in the future.
    I'd like to know the opinion of the rest of the team, my point of view is based on our health system, it might be inadequate for someone else's.
    • Sebastian (18 Dec 2007)
      I agree, this should be done in the same archetype, much like diagnoses wouldn't be in different archetypes even if setting/scope etc. is different.
      • Beatriz (18 Dec 2007)
        Here in Brazil we register the to different concepts with two different domains ( for primary care, and as we call - "pronto-atendimento_  - sort of outpatient emergency not for very serious cases Reason for encounter - we use ICD-10 chapter Z Chief Complain - as part of the patient history - so far is being recorded as text - we're considering perhaps ICPC in Portuguese but text is OK for now Check-list conditions and diagnosis - ICD-10 (mandatory in the country).
        We already made those constraints in the archetypes we translated.
  • Ian (18 Dec 2007)
    There is no doubt in my mind that these are exactly the same thing and do not require separate archetypes. This is a simple statement/encapsulation of why the patient/ client has asked for assistance. I would argue that it could equally apply over any possible professional encounter, completely outwith the clinical domain e.g. lawyer, archetype.
    The value is in briefly describing the patient's understanding as they seek advice. I am not sure how much semantic validity or value that might have. In my practice, which was heavily POMR orientated we wrote a simple phrase in the right hand margin to try to capture the overall nature of the consultation which may have included both the clinician and patient perspective.
    Sure the scope my vary by speciality but so may that for 'diagnosis'. In a sense 'presenting complaint' is the patient's 'diagnosis'. If the purpose of the archetype is clearly generic with examples given in the use and misuse, could the renaming of the node just be left to the template, without the need for a choice of terms.
    • Sam (18 Dec 2007)
      OK - this is very useful. I think the issue has reduced to whether we have names for this in the archetype - like Chief complaint, reason for encounter and Presenting complaint or we leave it to the template. My only concern here is that we are not precise enough. We can do this verbally - but I do think it could be useful in English - any obvious translations in Portuguese or other languages. Is Ian right and there might usefully be a lot of different names that are sensible. Is it worth narrowing these at all?
  • Omer (18 Dec 2007)
    "Chief Complaint" is the most common expectation here in Turkey. Reason for Encounter is mostly understood as patient admission way (i.e.: emergency, scheduled exam, routine-checkup, control, etc...). Also, most of the insurance companies have a main field of "Chief/Main Complaint" along with it's "Duration or Since When". I believe, having a simple and to the point archetype with only Chief_Complaint field (allowing the use of, most likely, ICD-10x) and Duration field would be very handy.
  • Heather (18 Dec 2007)
    In the NHS modeling we have made use of the Story OBSERVATION a huge amount.  We deliberately named the archetype 'Story' to be able to capture a 'History of Presenting Complaint' for any type of formal clinical care history taking, or just a patient 'story' as they might want to record in their Personal Health Record - so it is multipurpose and named to be as open and non-medical as possible, therefore used in all scenarios.  We usually rename it to "Presenting Complaint"  in the clinical templates in NHS use - ie Emergency/Maternity/ENT.
    Within the 'Story' archetype is the ability to include other cluster archetypes to facilitate detailed and structured data capture about the presenting story ie symptom, the symptom-pain specialization, event and a general issue cluster.
    Interestingly, in my mind "Reason for Encounter" is a more formal and specific entity which is for capturing the primary reason for a person seeking healthcare intervention - a short and pithy summary, if you like.  And this complements the free text attributes of the 'Story' archetype.
    However when I put both 'Reason for Encounter' EVALUATION (an evaluation for its' persistence value, I think) and 'Story' OBSERVATION into a recent NHS template for Hearing Loss assessment in outpatients, I had howls of protest - that "these were the same thing"!  I'm not so sure that they are. 
    Interestingly, (and maybe confusingly), I have just realized that there is also a Reason for encounter SECTION in the openEHR section in svn - with slots open for observations and evaluations.  So a number of other ways to approach it too.
  • Jag (03 Jan 2008)
    To confuse/clarify matters further,
    In my opinion for what its worth:
    - Reason for encounter is completely different from chief complaint.
    - Reason for encounter is the reason why a person may have an *encounter* with the health professional/provider.
    - Chief complaint is only relevent when a person has symptoms and signs for which he consults a health professional/provider
    A person may have an encounter with a health professional/provider for several reasons.
    a.) *Consultation*- when there are symptoms and signs including a chief complaint which prompt him to seek the help
    b.) *Treatment*: eg chemotherapy sessions. Where a diagnosis has already been established and the patient only attends for receiving treatment.
    c.) *Investigation/further investigation*: Where a consultation pertaining to the complaint has already been carried out and the patient is attending to have further investigations/special investigations performed.
    d.) A *routine health check* when there are no compaints. I think the key word here is encounter.
    My other thought regarding Chief complaint is - there may be more than one complaint of equal importance.
    Separate archetypes for *Reason for Encounter* and perhaps *Presenting Symptoms and Signs * or *Presenting Complaints*
    • Heather (03 Jan 2008)
      Thanks Jag.
      Must say that I agree with your view here.
    • Omer (04 Jan 2008)
      Very clear... I agree...Thanks Jag
    • Beatriz (04 Jan 2008)
      That was exactly what I was trying to say. At least this is what we use in Brazil.

Summary  13Feb2008:
Hmm - varied views.
I'll take a risk here and try to summarise and add a few more questions. The initial comments (above) seemed to see the two concepts as very similar, but the last few (chronologically) seemed to differ and get some support.  So I have gone for the latter view, but comment below if you think that I've got it wrong and keep the dialogue going...

  • Reason for Encounter is a different clinical concept from Presenting (or chief) Complaint - DO YOU AGREE?
    • "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 or something that happened to the patient.  
      • There may be multiple symptoms so better to consider Presenting complaint (and enable as many as needed) rather than Chief complaint (which implies one main one).
      • May be better not to limit it to 'symptoms', but open it to broader issues as well eg want to stop smoking, lose weight, relationship problems (ie issues).
        • Currently the concept "Presenting Complaint" concept is reflected by an archetype "Story" in NHS work - 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.  IS THIS APPROPRIATE?  SHOULD PRESENTING COMPLAINT BE A SPECIALISATION OF STORY OR RENAME IN TEMPLATES?