When the chief complaint is a sign or symptom communicated by the patient, the physician, based on the documentation guidelines, is supposed to ask questions to get a complete description and chronological account of the problem to be treated. A chief complaint is a concise statement of the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. Documentation Guidelines; Coding & Documentation COMPLIANCE AUDITS: Top 5 mistakes all providers should avoid. Here are the top five mistakes I have identified that many providers are making when it comes to documentation: #1 Chief complaint not documented appropriately The documentation requirements for a new patient level 3 visit are The problem: Official guidelines say that the chief complaint, the main reason for the patient's visit, must appear at the top of the physician's note or in the history of present illness (HPI) section, says Jim Collins, president of The Cardiology Coalition in Matthews, NC. • referral source, reason for referral, chief complaint relevant to OT's domain of concern Guidelines for Effective Documentation. 6 terms. Documentation Guidelines for Musculoskeletal PT. 14 terms. Guidelines for Documentation (Ch.16) Features. Quizlet Live. Quizlet Learn. Are you complying with Palmetto's Coding and Documentation Requirements? By Joy Newby, LPN, CPC, PCS, Coding and Documentation Requirements. The chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other BBB Coding. Coding lecture. STUDY. PLAY. Terms in this set () 47 Slides. Documentation Guidelines for Evaluation and Management Services, 1997 comprehensive history for the chief complaint of a "sore throat." T/F. FALSE. FOUR levels of the EXAM. The chief complaint is very important, as it is the core defining point from which the entire note will be judged. Therefore, not including a clear and concise chief complaint