Wiki problem found on exam added to the chief complaints

[CatchTheWind]

A patient comes in a Problem A (the "chief complaint"), but during the exam the provider also found problem B. Can problem B be added as a secondary chief complaint?

(The reason we want to do this is that our software only gives us an HPI checklist for chief complaints. If a problem is not a "chief complaint," the provider has to free-text the HPI; also the software will not count this HPI toward the E/M level.)

 

[thomas7331]

A chief complaint is defined in 1995 guidelines as a 'concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.' I think this definition would encompass a situation where the problem was identified by the physician that required evaluation and don't think there would be any reason why you could not add that as a second chief complaint. I would recommend caution though about allowing your software to count elements and/or select E/M levels for your providers as this can create errors and compliance issues.