The Chief “Complaint” and History of Present Illness

The Chief “Complaint” (CC) and History of Present Illness (HPI) typically include the reason for the medical visit, a chronological account of symptoms associated with the patient’s experience of illness, and, when pertinent to the reason for seeking care, elements of the past medical history, demographics, and social history. When documenting these sections, we recommend critically examining the risk of introducing bias as it pertains to specific domains of medical documentation: gender, age, race/ethnicity, social history, positive and negative language, attributions, and quotations. In this chapter we provide examples of where bias may creep into language and suggest potential alternatives that use more neutral and patient-centered terminology.

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  1. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Cody Gehring & Renata Thronson
  1. Cody Gehring
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  1. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Christopher J. Wong
  2. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Sara L. Jackson

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Gehring, C., Thronson, R. (2023). The Chief “Complaint” and History of Present Illness. In: Wong, C.J., Jackson, S.L. (eds) The Patient-Centered Approach to Medical Note-Writing. Springer, Cham. https://doi.org/10.1007/978-3-031-43633-8_7

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