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 D
Explanation
A. Abandonment: Abandonment involves the discontinuation of care without proper transition, not failure to document.
B. Assault: Assault involves causing apprehension of imminent harm, which is not related to documentation.
C. Battery: Battery refers to physical harm or unauthorized touching, not documentation issues.
D. Negligence: Negligence involves a failure to provide adequate care or follow procedures, such as not documenting adverse reactions properly.
Correct Answer is B
Explanation
A. Ischemia: Ischemia refers to the lack of blood flow to tissues, which can lead to tissue damage or death, but it is not related to swelling due to fluid accumulation.
B. Edema: Edema is the correct term for tissue swelling caused by the accumulation of interstitial fluids, making this the correct choice.
C. Infarction: Infarction refers to tissue death due to a lack of blood supply, not to swelling caused by fluid accumulation.
D. Gangrene: Gangrene is the death of body tissue due to a lack of blood flow or severe infection, not related to fluid accumulation and swelling.