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 C
Explanation
A. Convulsions: Convulsions are not a common complication of phlebotomy; they are unrelated to the procedure.
B. Petechiae: Petechiae are small red spots that can occur but are less common than hematomas in phlebotomy.
C. Hematoma: A hematoma, or bruise, is the most common complication resulting from the accumulation of blood outside the vein after a blood draw.
D. Hypovolemia: Hypovolemia, or low blood volume, is not a common complication from routine phlebotomy.
Correct Answer is A
Explanation
A. Place the arm electrodes facing downward. The arm electrodes should be placed with the tabs facing downward to reduce the risk of artifacts on the EKG tracing caused by movement or improper lead contact.
B. Place the electrodes over bony prominences when possible. Electrodes should not be placed over bony prominences, as this can interfere with the accuracy of the EKG reading. Instead, they should be placed on soft tissue.
C. Place the leg electrodes downward. Leg electrodes should also be placed with the tabs facing downward to prevent artifacts, similar to the arm electrodes.
D. Place the chest electrodes in a straight line just below the nipple. Chest electrodes should be placed according to specific anatomical landmarks, not in a straight line, to ensure accurate heart rhythm tracing.