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 C
Explanation
A. Bone density test: Bone density tests are typically recommended for women starting around age 65 or earlier if risk factors are present, but they are not usually performed annually.
B. Dilated eye exam: While dilated eye exams are important, they are generally recommended every 1-2 years, not annually, unless specific conditions warrant more frequent exams.
C. Papanicolaou (Pap) test: The Pap test is recommended every 3 years for women aged 21-65 or every 5 years with HPV testing for those aged 30-65. Annual documentation is not required, but it is important to monitor this screening as part of preventative care.
D. Mammogram: Mammograms are typically recommended every 1-2 years for women starting at age 40, not annually.
Correct Answer is B
Explanation
A. Safety data sheet (SDS): SDS provides information on handling and disposing of hazardous materials, not specifically on infection control or disease prevention.
B. Standard precautions: Standard precautions are infection control practices used to prevent the spread of disease in healthcare settings, such as hand hygiene and using personal protective equipment.
C. CLIA: CLIA (Clinical Laboratory Improvement Amendments) regulates laboratory testing but does not specifically address disease prevention in patient interactions.
D. Exposure plan: An exposure plan is related to handling and reporting exposure to bloodborne pathogens, not general disease prevention.