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 C
Explanation
A. Taking aspirin within 12 hr of testing: Aspirin does not generally affect spirometry results.
B. Using sedatives within 1 hr of testing: Sedatives may affect respiratory function, but they are not a common consideration for spirometry preparation.
C. Exercising 2 hr prior to testing: Exercise can affect lung function temporarily, so it’s best to avoid vigorous exercise before a spirometry test.
D. Eating a heavy meal 4 hr prior to testing: While eating a heavy meal might cause some discomfort, it is less likely to affect the spirometry results significantly compared to exercise.
Correct Answer is C
Explanation
A. Glutaraldehyde: Glutaraldehyde is used for high-level disinfection of medical equipment, not for cleaning blood spills.
B. Isopropyl alcohol: While isopropyl alcohol is used for disinfection, it is not the preferred choice for blood spills due to its lower efficacy against certain pathogens.
C. Bleach: A bleach solution is effective for disinfecting surfaces contaminated with blood, as it is effective against a broad range of pathogens, including bloodborne viruses.
D. Iodine compounds: Iodine is used for antiseptic purposes on skin but is not ideal for disinfecting blood spills on surfaces.