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. 1/4 inch: A 1/4 inch border is too small to be considered a standard contaminated area. The correct border size is larger.
B. 1/2 inch: A 1/2 inch border is also not standard; the correct contaminated border is larger.
C. 1 inch: The standard for sterile fields is to consider a 1-inch border around the edge of the sterile field as contaminated. This helps to prevent inadvertent contamination of sterile items.
D. 1 1/2 inches: A 1 1/2 inch border is unnecessarily large and exceeds the standard 1-inch margin considered contaminated.
Correct Answer is A
Explanation
A. Ensure the skin is clean and dry. This is the correct action. Sweating can interfere with electrode adhesion and signal quality, so the skin should be cleaned and dried to ensure a good contact for accurate EKG readings.
B. Apply conductive gel to the patient's chest. Conductive gel is typically used with certain types of electrodes, but in the case of disposable adhesive EKG electrodes, it is not necessary and may not improve tracing quality.
C. Shave the electrode sites. Shaving may be necessary if the patient has a lot of body hair, but it is not the first step when dealing with sweating. Drying the skin is more immediate and essential.
D. Place the electrodes below the clavicle. Electrode placement should follow standard EKG guidelines, and moving them to non-standard positions like below the clavicle can result in inaccurate readings.