The chief complaint should be written in which form?

• A. The clinician's interpretation
• B. The patient's own words
• C. The nurse's notes
• D. The final diagnosis

Answer: (B)

The chief complaint should be written in the patient’s own words because it records the reason they came in from their perspective, preserving the patient’s voice and guiding the initial history and questions without adding interpretation. This direct phrasing helps clinicians understand the primary concern clearly and sets the stage for a focused history of present illness that describes onset, location, quality, severity, timing, and factors that worsen or relieve symptoms. If direct quotes aren’t possible, you should still reflect the patient’s exact meaning as closely as possible, and use quotation marks for any verbatim parts.

Why this is best: it avoids bias from the clinician’s viewpoint and ensures the patient’s concern is front and center in the chart, which is essential for accurate triage and planning of the exam. The other sections—clinician interpretation, nursing notes, and the final diagnosis—come later in the chart, after assessment and evaluation, and do not capture the patient’s initial explanation of why they sought care.