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. Consent form: A consent form is a document that gives permission for medical procedures or treatments and is not the same as a superbill.
B. Assignment of benefits: Assignment of benefits is a document that allows the insurance company to pay the provider directly, not a billing form used to summarize charges.
C. Encounter form: A superbill is also known as an encounter form. It details the services provided, diagnosis codes, and charges for a patient’s visit.
D. Advanced beneficiary notice: An advanced beneficiary notice informs patients about services that Medicare may not cover and is not related to billing or charges.
Correct Answer is D
Explanation
A. Yellow: The yellow tube, used for blood cultures, is typically collected first to prevent contamination.
B. Light blue: The light blue tube is used for coagulation studies and should be collected before tubes containing additives that could interfere with coagulation tests.
C. Red: The red tube, which may contain no additives or a clot activator, is usually collected after the light blue tube.
D. Gray: The gray tube is used for glucose testing and should be filled last as it contains additives that could interfere with other tests if collected earlier.