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. "Clean the perineal area from back to front.": For females, cleaning should be done from front to back to avoid contamination from fecal matter. For males, cleaning should be done around the urethral opening.
B. "Void a small amount into the toilet before voiding into the cup.": This helps to flush out any contaminants from the urethra, ensuring that the urine collected in the cup is as clean as possible.
C. "Urinate directly into the container with preservative.": Urinating directly into a container with preservative can contaminate the sample and is not recommended for a clean catch specimen.
D. "Collect all urine from start to finish.": The clean catch method specifically involves discarding the initial stream of urine and collecting the midstream to avoid contaminants.
Correct Answer is B
Explanation
A. Call for the provider. Calling for the provider may not address the immediate concern of the patient’s anger and can escalate the situation if not handled calmly first.
B. Speak to the patient using a low tone of voice. Speaking in a calm and low tone can help de-escalate the situation and show that the assistant is attentive and empathetic.
C. Tell the patient to calm down. Telling a patient to calm down can come across as dismissive and may worsen their frustration.
D. Respond in the same tone as the patient. Matching the patient’s angry tone is unprofessional and can escalate the situation further.