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 B
Explanation
A. Safety data sheet (SDS): SDS provides information on handling and disposing of hazardous materials, not specifically on infection control or disease prevention.
B. Standard precautions: Standard precautions are infection control practices used to prevent the spread of disease in healthcare settings, such as hand hygiene and using personal protective equipment.
C. CLIA: CLIA (Clinical Laboratory Improvement Amendments) regulates laboratory testing but does not specifically address disease prevention in patient interactions.
D. Exposure plan: An exposure plan is related to handling and reporting exposure to bloodborne pathogens, not general disease prevention.
Correct Answer is C
Explanation
A. Reschedule the patient for another appointment. Rescheduling might not be necessary if the patient’s concerns can be addressed in the current appointment.
B. Remind the patient the procedure is already scheduled. Reminding the patient about the scheduled procedure without addressing their concerns can come off as dismissive.
C. Relay the information to the provider. The medical assistant should communicate the patient’s additional concerns to the provider so they can be addressed before proceeding with the treatment.
D. Ask another medical assistant to speak to the patient. The medical assistant who is currently interacting with the patient should address the concerns or relay them to the provider, rather than passing the responsibility to another assistant.