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 (AC) interference: AC interference is caused by electrical equipment near the EKG machine and appears as uniform, small, rapid spikes. It is not caused by patient movement.
B. Arrhythmia: An arrhythmia refers to an abnormal heart rhythm and is related to cardiac function, not patient movement.
C. Somatic tremor: Somatic tremor is caused by voluntary or involuntary muscle movement, such as a patient moving their arm, which creates artifact on the EKG tracing that appears as irregular, erratic spikes.
D. Interrupted baseline: An interrupted baseline occurs when the electrical connection is lost, often due to a lead falling off, not due to patient movement.
Correct Answer is D
Explanation
A. The number of no-shows on the patient's record: While the number of no-shows can be relevant for overall management, it is not the primary consideration when scheduling a specific appointment.
B. The referring provider's recommendation: Referring provider recommendations are important but typically influence the initial appointment or consultation rather than ongoing scheduling.
C. The amount of deductible the patient owes for their insurance: Insurance deductible information is important for billing but does not directly affect the scheduling of appointments.
D. The amount of time required based on the reason for visit: It is essential to consider the time needed for the appointment based on the patient's reason for the visit to ensure that the appointment is appropriately scheduled and sufficient time is allocated.