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 A
Explanation
A. Obtain a regular referral: If the cardiologist consultation has not been initiated, the medical assistant should obtain or process the referral to ensure the patient sees the specialist as required.
B. Have the patient obtain a second opinion: This action is unnecessary and might be premature if the original referral was not processed.
C. Initiate a referral to a different cardiologist: There is no need to refer to a different cardiologist unless there is a specific issue with the initial referral or cardiologist.
D. Send the patient to the emergency department for evaluation: Sending the patient to the emergency department is not appropriate unless the patient has an urgent issue. The issue here is with the referral process, not an emergency.
Correct Answer is A
Explanation
A. Obtain precertification: Obtaining precertification from the insurance company is often required before scheduling a surgical procedure to ensure that the procedure will be covered under the patient’s insurance plan.
B. Code the diagnosis and procedure: Coding the diagnosis and procedure is typically done after the procedure has been scheduled and is part of the billing process.
C. Complete the CMS-1500 claim form: The CMS-1500 claim form is used for billing and is completed after the procedure has been performed, not before scheduling.
D. Review the claim information: Reviewing claim information is part of the post-procedure billing process, not the scheduling process.