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 D
Explanation
A. Take the patient's pulse for 5 seconds and multiply by 10: Measuring for 5 seconds and multiplying by 10 is less accurate due to the short measurement time.
B. Take the patient's pulse for 15 seconds and multiply by 2: While this method is more accurate than taking it for 5 seconds, the recommended practice is to measure for 30 seconds for better accuracy.
C. Take the patient's pulse for 30 seconds and multiply by 4: This would be used to determine a pulse rate per minute from a 15-second measurement, not 30 seconds.
D. Take the patient's pulse for 30 seconds and multiply by 2: This method provides a precise measurement of the pulse rate, as taking the pulse for 30 seconds and then multiplying by 2 gives the number of beats per minute.
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.