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In which of the following sections of the progress note should a medical assistant document a patient's chief complaint?

A.

Subjective

B.

Objective

C.

Review of systems

D.

Assessment

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. Computerized physician order entry: Computerized physician order entry (CPOE) is used by providers to enter and manage orders for tests, medications, and treatments, not for patient requests.

B. Patient portal: A patient portal is a feature of an electronic health record that allows patients to request refills, schedule appointments, and access their health information online.

C. Prescribing guide: A prescribing guide helps providers make decisions about medications but does not allow patients to make requests.

D. Computer on wheels: A computer on wheels (COW) is a mobile workstation used by healthcare providers for various tasks but does not directly facilitate patient requests.

Correct Answer is B

Explanation

A. Avoiding intense eye contact: Avoiding intense eye contact is generally respectful and can be appropriate depending on cultural norms.


B. Reassuring the patient by touching them: In some Muslim cultures, physical contact between individuals of the opposite gender who are not family members may be considered inappropriate.


C. Maintaining distance from the patient: Maintaining a respectful distance is generally appropriate and often preferred in various cultures.


D. Using gestures cautiously: Using gestures cautiously is respectful and avoids miscommunication.

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