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. Have the patient hold on to the wall while weighing. Holding onto the wall can be unsafe and can affect the accuracy of the weight measurement.
B. Position a walker over the scale. Positioning a walker over the scale can affect the scale's accuracy and the patient's balance.
C. Position a cane on the scale between her feet. Placing a cane on the scale can affect weight measurement and may not provide accurate results.
D. Have the patient sit in a chair on the scale. Weighing a patient sitting in a chair on the scale can provide an accurate measurement for patients with balance issues.
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.