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. American National Standards Institute (ANSI): ANSI is involved in developing and promoting standards but does not specifically focus on hazardous chemical disposal.
B. Occupational Safety and Health Administration (OSHA): OSHA provides guidelines and regulations for workplace safety, including the proper disposal of hazardous chemicals.
C. Centers for Medicare and Medicaid Services (CMS): CMS oversees healthcare quality and insurance but does not provide guidelines for hazardous chemical disposal.
D. Centers for Disease Control and Prevention (CDC): The CDC focuses on public health and disease prevention but does not provide specific guidelines for hazardous chemical disposal.
Correct Answer is C
Explanation
A. Authentication: Authentication verifies user identities but does not act as a barrier between networks and the internet.
B. Audit trail: An audit trail tracks changes and access to records but does not act as a barrier.
C. Firewall: A firewall acts as a barrier between the network and the internet, helping to protect sensitive data and ensure HIPAA security.
D. Virus protection software: Virus protection software helps protect against malware but does not specifically act as a barrier between networks and the internet.