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. Offer to review and research the problem: Offering to review and research the billing concern shows willingness to address the issue and provides the patient with assistance.
B. Inform the patient you will ask the provider to call them: Billing concerns should be handled by the administrative or billing department, not the provider.
C. Have the patient fill out a HIPAA form before proceeding: A HIPAA form is not required for addressing billing concerns; it is for accessing or disclosing protected health information.
D. Recommend the patient contact their bank: The bank is not responsible for billing concerns related to medical services; the issue should be addressed directly with the healthcare facility.
Correct Answer is C
Explanation
A. Chlamydia pneumoniae: While Chlamydia pneumoniae can cause respiratory infections, it is not typically associated with large-scale epidemics.
B. Clostridium difficile: Clostridium difficile causes antibiotic-associated diarrhea and colitis, but it is not commonly associated with epidemics.
C. Influenza type A: Influenza type A is known for causing seasonal epidemics and pandemics due to its ability to mutate rapidly and spread easily.
D. Mycobacterium tuberculosis: Mycobacterium tuberculosis causes tuberculosis, which is a concern for outbreaks but not typically associated with widespread epidemics like influenza.