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. 99.6°F: This temperature is higher than expected for an axillary reading. Axillary temperatures are generally lower than oral temperatures.
B. 98.6°F: This reading matches the oral temperature. However, axillary temperatures are usually lower by approximately 1°F compared to oral temperatures.
C. 97.6°F: This is the correct answer because axillary temperatures tend to be about 1°F lower than oral temperatures.
D. 96.6°F: This reading is lower than typically expected for an axillary temperature and would indicate hypothermia, which is not expected if the oral temperature was normal.
Correct Answer is C
Explanation
A. When cleaning instruments for sterilization: Hand sanitizer is not appropriate for cleaning or sterilizing instruments; proper cleaning and sterilization procedures must be followed.
B. When assisting with a minor office surgery: Hand sanitizer is not recommended for procedures requiring sterile technique; hand washing with soap and water is preferred.
C. When hands are not visibly soiled: Hand sanitizer can be used effectively when hands are not visibly dirty, as it helps reduce microbial load.
D. When transferring urine to a collection tube: Hand sanitizer is not suitable for this task; thorough hand washing is necessary to prevent contamination.