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 D
Explanation
A. Abandonment: Abandonment involves the discontinuation of care without proper transition, not failure to document.
B. Assault: Assault involves causing apprehension of imminent harm, which is not related to documentation.
C. Battery: Battery refers to physical harm or unauthorized touching, not documentation issues.
D. Negligence: Negligence involves a failure to provide adequate care or follow procedures, such as not documenting adverse reactions properly.
Correct Answer is A
Explanation
A. Deflate the cuff slowly until the last sound is heard. The diastolic reading is determined when the last sound (Korotkoff sound) is heard as the cuff is deflated.
B. Listen for the first sound through the stethoscope: The first sound corresponds to the systolic reading, not the diastolic.
C. Document the reading when the gauge needle jumps: The gauge needle jump is not a reliable indicator of blood pressure readings.
D. Inflate the cuff to at least 180 mm Hg, deflate the cuff slowly, and listen for the first sound: Inflating to 180 mm Hg is unnecessary and might cause discomfort; also, the first sound is the systolic reading, not the diastolic.