Abstract
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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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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DOI: https://doi.org/10.1007/978-3-031-43633-8_7
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