What are examples of chief complaints in a SOAP (Subjective, Objective, Assessment, Plan) note?

Examples of Chief Complaints in SOAP Notes

The chief complaint section in a SOAP note should clearly document the patient's primary reason for seeking medical care, using the patient's own words whenever possible.

Purpose of Chief Complaints

Chief complaints serve as the foundation of the medical record, establishing the primary reason for the patient's visit. They appear in the Subjective (S) portion of the SOAP note format 1. Proper documentation of chief complaints is essential for:

• Establishing the focus of the clinical encounter
• Guiding the subsequent examination and diagnostic process
• Supporting medical necessity for billing and coding
• Creating a legal record of the patient's presenting concerns

Common Chief Complaint Examples

Pain-Related Complaints

• "Chest pain, pressure, tightness, or heaviness" 1
• "Pain that radiates to neck, jaw, shoulders, back, or one or both arms" 1
• "Joint, leg, ankle, and knee pain" 2
• "Abdominal pain" 3
• "Severe epigastric pain" 1

Respiratory Complaints

• "Persistent shortness of breath" 1
• "Dyspnea" 3

Neurological Complaints

• "Weakness, dizziness, lightheadedness" 1
• "Loss of consciousness" 1
• "Neurologic complaints" 3

Gastrointestinal Complaints

• "Indigestion or heartburn" 1
• "Nausea and/or vomiting associated with chest discomfort" 1

Mental Status Complaints

• "Confusion, disorientation, lethargy" 4
• "Agitation, altered behavior" 4
• "Hallucinations, delusions" 4

Other Common Complaints

• "Fever" 3
• "Non-specific symptoms" 3

Documentation Format

When documenting chief complaints, follow these guidelines:

1. Use the patient's own words whenever possible, placed in quotation marks
2. Be specific about duration - include when symptoms began
3. Document severity - use patient's description or standardized scales
4. Note associated symptoms - include relevant accompanying symptoms
5. Avoid medical terminology in the chief complaint section unless directly quoted from the patient

Example Format:

"[Symptom] for [duration]" or "[Patient's exact words describing primary concern]"

Special Considerations

Atypical Presentations

Be aware that certain populations may present with atypical symptoms:

• Women may present more frequently with atypical chest pain 1
• Diabetic patients may have atypical presentations due to autonomic dysfunction 1
• Elderly patients may present with generalized weakness, stroke, syncope, or mental status changes rather than typical symptoms 1

Multiple Complaints

When patients present with multiple complaints:

• Document the most significant or concerning complaint first
• Include secondary complaints in order of importance
• Consider using numbered lists for clarity

Emergency Situations

In emergency settings, chief complaints requiring immediate triage include:

• Chest pain or severe epigastric pain with components typical of myocardial ischemia 1
• Central/substernal compression or crushing chest pain 1
• Pressure, tightness, heaviness, cramping, burning, or aching sensation 1
• Unexplained indigestion, belching, epigastric pain 1
• Radiating pain in neck, jaw, shoulders, back, or arms 1

Documentation Pitfalls to Avoid

1. Vague complaints - "Not feeling well" should be clarified with more specific symptoms
2. Diagnostic language - Avoid using diagnostic terms in the chief complaint (e.g., "Pneumonia" instead of "Cough, fever, and shortness of breath")
3. Missing duration - Always document how long symptoms have been present
4. Omitting severity - Include the patient's description of symptom severity
5. Inconsistent documentation - Ensure the chief complaint aligns with the rest of the SOAP note

Remember that proper documentation of chief complaints not only guides clinical care but also serves important legal, billing, and quality improvement purposes. Using clear, concise language that accurately captures the patient's primary concern is essential for effective SOAP note documentation.