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 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.