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 D
Explanation
A. Cotton balls: Cotton balls are not required for the autoclave process and do not aid in sterilization.
B. Masking tape: Masking tape is not used in the autoclave process; it does not contribute to the sterilization of instruments.
C. Tap water: Tap water is not recommended for use in autoclaves; distilled or deionized water is preferred to avoid mineral deposits.
D. Sterilization indicators: Sterilization indicators (such as indicator strips or tape) are used to confirm that the autoclave has reached the necessary temperature and pressure for effective sterilization.
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.