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. Fire extinguishers' pins are intact: Ensuring that fire extinguishers are properly maintained, including checking that the pins are intact, is essential for fire safety preparedness.
B. Multiplug adapters are not in use: While using multiplug adapters can be a safety concern, it is not directly related to fire preparedness.
C. Sprinkler heads are unobstructed: This is important for fire safety but is more related to fire suppression rather than the preparation aspect.
D. One emergency exit is available: Ideally, there should be multiple emergency exits; having only one is a safety concern rather than a preparedness measure.
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.