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 A
Explanation
A. Anterior: The term "anterior" refers to the front of the body, so it is appropriate for describing a rash on the front of the patient's arm.
B. Posterior: "Posterior" refers to the back of the body, which is not the location of the rash in this scenario.
C. Lateral: "Lateral" refers to the side of the body. While the rash may be on the side of the arm, it is more specifically described as anterior.
D. Medial: "Medial" refers to the midline of the body, not specifically to the front of the arm.
Correct Answer is B
Explanation
A. Wipe away the first five drops of blood after puncturing: Only the first drop of blood should be wiped away to remove any tissue fluid, not the first five drops.
B. Apply even pressure to the finger during the collection: Applying even pressure helps to promote blood flow without causing hemolysis or excessive squeezing, which could affect test results.
C. Puncture the index finger at the tip: The recommended site for a capillary puncture is the side of the middle or ring finger, not the tip of the index finger.
D. Puncture parallel to the fingerprint: The puncture should be made perpendicular to the fingerprint ridges to ensure an adequate blood flow and reduce the risk of blood running along the ridges.