主訴
主訴(chief complaint,簡稱CC),是病史詢問的第二個步驟,是病患或家屬有關症狀、問題、疾病、診斷、或医生建議回診等,就診原因的簡單描述[1]。患者對醫生、護理師或是其他醫療保健專業人員提出的初步資訊有助於鑑別診斷的建議。
有些情形下,病患提出主訴的性質會決定此醫療是否在醫療保險的範圍內[2]。
盛行率
编辑主訴資訊的搜集可以用在公共卫生議題的處理上[4]。有些主訴在特定環境及特定人群中特別常見。疲勞是病患去就診的十大原因之一[5]。在緊急醫療的情形(例如急诊室),胸痛是最常見的主訴原因之一[6]。腹痛也是急诊室常見的主訴原因之一[7]。若是已住進療養中心,去急诊室就診的病患,常見的主訴有呼吸系統症狀、精神狀態改變、腸胃道症狀以及跌倒[8]。
相關條目
编辑參考資料
编辑- ^ VI. Evaluation and Management (E/M) Services. Compliance Training Manual. www.usc.edu. [2018-07-03]. (原始内容存档于2001-05-03).
- ^ coding q & a - Medical Vs. Vision Insurance. Optometric Management. July 1, 2004 [2018-07-03]. (原始内容存档于2016-12-25).
- ^ Shah, Nayankumar. Taking a history: Introduction and the presenting complaint. Student BMJ. 2005, 13: 309–52 [2018-07-03]. doi:10.1136/sbmj.0509314 (不活跃 2017-01-15). (原始内容存档于2017-09-05).
- ^ Implementation Guide for Transmission of Patient Chief Complaint as Public Health Information using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol (PDF). Centers for Disease Control and Prevention. May 27, 2003 [2018-07-03]. (原始内容存档 (PDF)于2006-10-23).
- ^ Nelson, E; Kirk, J; McHugo, G; Douglass, R; Ohler, J; Wasson, J; Zubkoff, M. Chief complaint fatigue: A longitudinal study from the patient's perspective. Family practice research journal. 1987, 6 (4): 175–88. PMID 3455125.
- ^ Differentiating Chest Pain. Emergency Medicine. [2018-07-03]. (原始内容存档于2006-11-17).
- ^ Graff, Louis G.; Robinson, Dave. Abdominal Pain and Emergency Department Evaluation. Emergency Medicine Clinics of North America. 2001, 19 (1): 123–36. PMID 11214394. doi:10.1016/S0733-8627(05)70171-1.
- ^ Ackermann, Richard J; Kemle, Kathy A; Vogel, Robert L; Griffin, Ralph C. Emergency Department Use by Nursing Home Residents. Annals of Emergency Medicine. 1998, 31 (6): 749–57. PMID 9624316. doi:10.1016/S0196-0644(98)70235-5.