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. Obtain precertification: Obtaining precertification from the insurance company is often required before scheduling a surgical procedure to ensure that the procedure will be covered under the patient’s insurance plan.
B. Code the diagnosis and procedure: Coding the diagnosis and procedure is typically done after the procedure has been scheduled and is part of the billing process.
C. Complete the CMS-1500 claim form: The CMS-1500 claim form is used for billing and is completed after the procedure has been performed, not before scheduling.
D. Review the claim information: Reviewing claim information is part of the post-procedure billing process, not the scheduling process.
Correct Answer is B
Explanation
A. Applying powder to the site: Powder should not be applied to the site as it can interfere with electrode adhesion and signal transmission.
B. Wiping the site with alcohol and allowing to air dry: Wiping the site with alcohol helps to remove oils and debris, improving electrode adhesion and signal quality. Allowing the site to dry ensures proper contact between the electrode and the skin.
C. Taping the electrodes to the skin: Taping is not necessary if the electrodes are properly adhered with the adhesive backing. Excessive taping could cause discomfort or interfere with the electrode function.
D. Allowing the electrodes to sit for several hours before application: Electrodes should be applied immediately after preparation. Allowing them to sit for an extended period is not necessary and does not improve the quality of the EKG.