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. Perform a sterile hand scrub: While sterile technique is important in many procedures, a sterile hand scrub is not specifically necessary for suture removal.
B. Lift the knot toward the wound: Lifting the knot towards the wound helps to ease the removal of the suture by reducing tension on the skin, making the procedure easier and less painful.
C. Begin cutting the sutures in the middle of the wound: Sutures should be cut close to the skin, not in the middle, to ensure proper removal and avoid causing unnecessary trauma to the wound.
D. Clean the wound with a disinfectant: Cleaning the wound with a disinfectant is not necessary before suture removal and might irritate the wound. Instead, the area should be cleaned after suture removal if needed.
Correct Answer is D
Explanation
A. An adult patient is watching a demonstration on the proper use of a meter-dose inhaler: This is related to managing a respiratory condition, not directly to communicable disease prevention.
B. An adult patient is being shown how to safely lift a heavy object: This pertains to body mechanics and injury prevention, not communicable disease prevention.
C. An older adult patient is listening to an explanation of risks and benefits of the flu vaccine: Although the flu vaccine helps prevent disease, the specific focus is not directly on communicable disease prevention strategies.
D. A school-age patient is being taught about cough etiquette: Teaching cough etiquette is a direct method of preventing the spread of communicable diseases.