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. Stress test: A stress test, or exercise stress test, involves monitoring the heart's activity with an EKG while the patient exercises on a treadmill or stationary bike. This test assesses how the heart performs under physical stress.
B. Holter monitor: A Holter monitor is a portable EKG device worn by the patient for 24-48 hours to continuously record heart activity in their daily life, not during exercise.
C. Echocardiogram: An echocardiogram uses ultrasound to visualize the heart's structures and is not performed while the patient is exercising.
D. Cardiac event monitor: A cardiac event monitor is used to record heart activity when the patient experiences symptoms, typically worn for weeks to months, and is not specifically for exercise testing.
Correct Answer is D
Explanation
A. Abandonment: Abandonment involves the discontinuation of care without proper transition, not failure to document.
B. Assault: Assault involves causing apprehension of imminent harm, which is not related to documentation.
C. Battery: Battery refers to physical harm or unauthorized touching, not documentation issues.
D. Negligence: Negligence involves a failure to provide adequate care or follow procedures, such as not documenting adverse reactions properly.