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: Alcohol can be used for cleaning but may not be sufficient for all minor surgical preparations. It is not considered an antiseptic in the context of preoperative skin cleaning.
B. Normal saline: Normal saline is used for irrigation and wound cleaning but does not have antiseptic properties.
C. Disinfectant: Disinfectants are used to clean surfaces and equipment but are not typically used directly on the skin for surgical preparation.
D. Antiseptic: Antiseptics, such as iodine-based solutions or chlorhexidine, are used to clean the skin and reduce the risk of infection before a minor surgical procedure.
Correct Answer is C
Explanation
A. Convulsions: Convulsions are not a common complication of phlebotomy; they are unrelated to the procedure.
B. Petechiae: Petechiae are small red spots that can occur but are less common than hematomas in phlebotomy.
C. Hematoma: A hematoma, or bruise, is the most common complication resulting from the accumulation of blood outside the vein after a blood draw.
D. Hypovolemia: Hypovolemia, or low blood volume, is not a common complication from routine phlebotomy.