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 A
Explanation
A. Advise them that privacy regulations prevent releasing patient information regardless of their relationship to the patient: Privacy regulations, such as those outlined in HIPAA, restrict the release of patient information without proper authorization, regardless of the inquirer’s relationship to the patient.
B. Verbally share the patient information with them since they are the subscriber on the patient's medical insurance: Even if the partner is the insurance subscriber, patient information cannot be disclosed without the patient’s explicit authorization.
C. Reassure them that they have nothing to worry about since their partner's visit was only a follow-up to a minor surgery: Providing details about the visit without authorization violates patient privacy and confidentiality.
D. Instruct them to provide proof of identity prior to providing the requested information: Proof of identity is not sufficient without a medical records release authorization form to disclose patient information.
Correct Answer is C
Explanation
A. Alternating current: Alternating current interference is due to electrical equipment, not patient movement or talking.
B. Interrupted baseline: An interrupted baseline occurs when there is a break in the electrical connection, often due to a loose lead, not because of patient talking.
C. Somatic tremor: Somatic tremor can occur due to muscle movement, including that caused by talking. This can result in erratic, uneven spikes on the EKG tracing.
D. Wandering baseline: A wandering baseline is usually caused by improper electrode placement or poor skin contact, not talking. However, excessive movement, including deep breaths or large chest movements during talking, can contribute to a wandering baseline.