Question

A medical assistant is taking a patient's history and entering it directly into the EHR. The patient's main reason for seeing the doctor is a severe migraine headache. If this office uses the CHEDDAR format of documentation, under which letter would this information be entered?

A. D
B. C
C. R
D. A

Answer 1

In the CHEDDAR format of documentation, the severe migraine headache would be documented under 'C' for 'Chief Complaint', which is the primary reason for the patient's visit to the doctor.

Step-by-step explanation:

The patient's main reason for seeing the doctor, which is a severe migraine headache, would be documented under the letter 'C' for 'Chief Complaint' in the CHEDDAR format of documentation. CHEDDAR stands for Chief Complaint, History, Examination, Details, Drugs and Dosages, Assessment, and Return Visit. Since the Chief Complaint is the primary reason the patient is seeking medical attention, it's essential to record this under the appropriate category to ensure clarity in the patient's medical records.