In which of the following sections of the progress note should a medical assistant document a patient's chief complaint?
Subjective
Objective
Review of systems
Assessment
The Correct Answer is A
A. Subjective: The chief complaint is a patient-reported symptom or concern and is documented in the subjective section of the progress note. This section includes the patient’s personal perspective and descriptions of their symptoms.
B. Objective: The objective section includes measurable or observable data, such as vital signs and physical examination findings, not the patient’s chief complaint.
C. Review of systems: The review of systems is a systematic approach to obtaining information about the functioning of various body systems but is not specifically where the chief complaint is documented.
D. Assessment: The assessment section contains the provider’s diagnostic impressions and conclusions about the patient’s condition, rather than the chief complaint.
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Correct Answer is A
Explanation
A. Label the tube after collection, including the date and time of collection: Labels should be applied to the tube immediately after the sample is collected to ensure accuracy and prevent mix-ups. Including the date and time helps with tracking and documentation.
B. Label the tube after collection, including the provider's name: While it is important to include identifying information, the primary focus should be on the date and time of collection to ensure the sample's accuracy.
C. Label the tube prior to collection, including the date and time of collection: Labels should be applied after the collection to avoid potential errors and ensure the correct sample is labeled.
D. Label the tube prior to collection, including the provider's name: Labeling prior to collection may lead to mistakes if the wrong sample is placed in the labeled tube. The correct practice is to label after collection.
Correct Answer is B
Explanation
A. Obtaining a tympanic reading: This procedure does not typically require gloves as it is non-invasive and does not involve contact with bodily fluids.
B. Administering a nebulizer treatment: Gloves should be worn during this procedure to maintain hygiene and prevent exposure to respiratory secretions.
C. Performing a visual acuity test: This test is non-invasive and does not require gloves.
D. Removing a cyst: This procedure typically requires more than gloves; it involves aseptic technique and potentially sterile equipment. Gloves are part of the preparation but are not sufficient on their own.