Coded Chief Complaints
Every medical (or digital health) encounter begins with a chief complaint.
Eliciting the patient’s chief complaint is one of the first tasks of health personnel in any medical encounter. The chief complaint serves to identify the patient’s primary reason for seeking care. A chief complaint, reason for encounter, “reason for visit” (RFV), or “reason for call” (RFC) should be recorded for each encounter.
Capturing and understanding the chief complaint is also the first step in every digital health encounter.
Health Navigator’s Coded Chief Complaints is a standardized clinical vocabulary that provides an acuity-coded reason for visit taxonomy, which can be used in:
- Answering service applications
- Artificial intelligence
- Digital health assistants (symptom checkers and health bots)
- Electronic health records
- Medical call center applications
- Telemedicine applications
How it works…
The Coded Chief Complaints vocabulary is a foundational element of the Health Navigator platform.
The CCC vocabulary is both granular and comprehensive, with over 470 chief complaints, covering over 99% of patient reasons for visit. Metadata built into the taxonomy include:
- Unique ID
- ICD10-CM, SNOMED coding
- Acuity (severity)
- Type (e.g., Symptom, Injury-Trauma, Disease, Treatment, Exposure)
- System (e.g., Gastrointestinal, Respiratory)
- Clinical documentation element
- Should an image be uploaded? (i.e., e-Visit intake, Telemedicine)
Th Coded Chief Complaints taxonomy is available in eight languages.
The Health Navigator Natural Language Processing engine can convert patient (and clinician) reason for visit free-text into the Coded Chief Complaint clinical vocabulary.
How it improves care…
Coded Chief Complaints is the first-ever, comprehensive, evidence-based, and time-tested vocabulary for capturing and storing the reason for visit. It reflects nearly 20 years of research, testing, and clinical use from millions of emergency department, medical call center, and telemedicine encounters.
How can this improve patient care? Here are some examples:
- Clinical Documentation: Telemedicine providers can use the Coded Chief Complaint vocabulary and associated metadata generated by the NLP engine to improve the efficiency and documentation quality of their patient encounters.
- Data and Analytics: Chief complaints are also a rich and mostly untapped source of data that has multiple other potential uses, including syndromic and disease surveillance, quality assurance activities, health services and hospital benchmarking, development of order sets for computer-assisted physician order entry, research, and education.
- Patient Safety and Satisfaction: Each patient has an expectation that the chief complaint will be addressed during their medical encounter. Failure to address the patient’s expectations and clearly understand the main symptoms can lead to patient dissatisfaction and sometimes medical mistakes.
- Workflow: Coded Chief Complaints crosswalk to over 500 Health Navigator documentation checklists, thousands of targeted plain language self-care advice statements, and a multitude of relevant internet resources. As one telemedicine leader said “… Health Navigator will ensure that a high quality, seamless user experience is consistently delivered”.