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. Alternating current: Alternating current interference is due to electrical equipment, not patient movement or talking.
B. Interrupted baseline: An interrupted baseline occurs when there is a break in the electrical connection, often due to a loose lead, not because of patient talking.
C. Somatic tremor: Somatic tremor can occur due to muscle movement, including that caused by talking. This can result in erratic, uneven spikes on the EKG tracing.
D. Wandering baseline: A wandering baseline is usually caused by improper electrode placement or poor skin contact, not talking. However, excessive movement, including deep breaths or large chest movements during talking, can contribute to a wandering baseline.
Correct Answer is A
Explanation
A. Bulimia: Bulimia nervosa is characterized by binge eating followed by compensatory behaviors such as vomiting, using laxatives, or excessive exercise to prevent weight gain.
B. Anorexia nervosa: Anorexia nervosa involves severe restriction of food intake and an intense fear of gaining weight but does not typically involve binge eating followed by purging.
C. Binge-eating disorder: Binge-eating disorder involves consuming large quantities of food without purging behaviors.
D. Elimination diet: An elimination diet is a method for identifying food intolerances or allergies and is not an eating disorder.