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Mrs. J brings her 11-month-old daughter to the clinic because she is "sleeping poorly and tugging at her ear when she is awake." Based on the information provided, the nurse can correctly record which of the following?

a. Chief complaint
b. Present illness
c. Past medical history
d. Symptom analysis

1 Answer

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Final answer:

The nurse can accurately record the chief complaint for Mrs. J's 11-month-old daughter, which is about her poor sleeping patterns and ear tugging behavior.

Step-by-step explanation:

Based on the information provided, the nurse can correctly record the chief complaint of Mrs. J's 11-month-old daughter. The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medical encounter. In this scenario, Mrs. J has brought her daughter to the clinic due to her poor sleeping patterns and the behavior of tugging at her ear when awake, which are the symptoms prompting the visit.

Understanding the differences in terminology is crucial for accurate clinical documentation. The present illness would require a detailed account of the symptoms and their development over time, while the past medical history encompasses the child's health history prior to the current symptoms. Symptom analysis would involve a systematic exploration of the symptom's characteristics, but it is not the term used to describe the record entry at the initial point of care.

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