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. Alcohol-based sanitizer: Alcohol-based sanitizers are effective for hand hygiene when there is no visible dirt or grease. They are generally used for routine hand antisepsis in situations where hands are not visibly soiled. For procedures involving body fluids, if hands are visibly soiled, traditional handwashing with soap and water is preferred.
B. Disinfectant scrub: Disinfectant scrubs are generally used for cleaning surfaces and are not appropriate for personal hand hygiene.
C. Antiseptic solution: Antiseptic solutions are used for cleaning skin before injections or procedures, not typically for hand hygiene.
D. Liquid soap: Liquid soap is suitable for handwashing, especially when hands are visibly soiled or after exposure to body fluids. In the context of body fluids, soap and water would be preferable to ensure effective removal of contaminants.
Correct Answer is A
Explanation
A. Place the arm electrodes facing downward. The arm electrodes should be placed with the tabs facing downward to reduce the risk of artifacts on the EKG tracing caused by movement or improper lead contact.
B. Place the electrodes over bony prominences when possible. Electrodes should not be placed over bony prominences, as this can interfere with the accuracy of the EKG reading. Instead, they should be placed on soft tissue.
C. Place the leg electrodes downward. Leg electrodes should also be placed with the tabs facing downward to prevent artifacts, similar to the arm electrodes.
D. Place the chest electrodes in a straight line just below the nipple. Chest electrodes should be placed according to specific anatomical landmarks, not in a straight line, to ensure accurate heart rhythm tracing.