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. NIH (National Institutes of Health): NIH conducts biomedical and public health research but does not regulate laboratory testing.
B. CLIA (Clinical Laboratory Improvement Amendments): This is correct. CLIA regulates laboratory testing and ensures quality standards in the clinical office setting.
C. HHS (Department of Health and Human Services): HHS oversees many health-related programs and agencies, but CLIA specifically regulates laboratory testing.
D. OSHA (Occupational Safety and Health Administration): OSHA regulates workplace safety, not laboratory testing.
Correct Answer is B
Explanation
A. Prone: The prone position (lying face down) is not suitable for venipuncture or for patients at risk of syncope.
B. Trendelenburg: The Trendelenburg position (lying flat with the legs elevated) can help prevent syncope by increasing venous return to the heart and improving blood flow to the brain.
C. Supine: While the supine position (lying flat on the back) is appropriate for venipuncture, the Trendelenburg position is preferred for patients with a history of syncope.
D. Fowler's: The Fowler's position (sitting or semi-sitting) is not suitable for preventing syncope during blood draws.