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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Sitting behind a desk and looking at the computer: This posture may appear distant and disinterested, as it creates a physical barrier and lacks engagement.
B. Sitting on the edge of a chair and leaning forward: This body language conveys attentiveness and engagement, indicating care and interest in the conversation with the patient.
C. Standing across the room. Standing across the room can seem impersonal and distant, which may not effectively communicate care and interest.
D. Standing over the patient: Standing over the patient can be intimidating and may convey dominance rather than care and support.
Correct Answer is B
Explanation
A. Ask the laboratory to send a link to an electronic version of the patient's report: The laboratory is not responsible for providing electronic versions of reports if paper reports are already received.
B. Scan the report into the patient's electronic health record (EHR): Scanning the report into the EHR ensures that the patient’s records are complete and accessible within the system.
C. Document that the results were delivered to the office in the patient's electronic health record (EHR): While documenting receipt is important, it does not substitute for the actual entry of the report into the EHR.
D. Sign their initials and place in the "to be filed" bin: Simply filing the report without scanning it into the EHR means the information is not integrated into the patient's digital health record.