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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. Glutaraldehyde: Glutaraldehyde is used for high-level disinfection of medical equipment, not for cleaning blood spills.
B. Isopropyl alcohol: While isopropyl alcohol is used for disinfection, it is not the preferred choice for blood spills due to its lower efficacy against certain pathogens.
C. Bleach: A bleach solution is effective for disinfecting surfaces contaminated with blood, as it is effective against a broad range of pathogens, including bloodborne viruses.
D. Iodine compounds: Iodine is used for antiseptic purposes on skin but is not ideal for disinfecting blood spills on surfaces.
Correct Answer is B
Explanation
A. Instruct the patient to collect the specimen and return it to the laboratory: For a valid drug screening, the specimen should be collected in the presence of a medical professional to prevent tampering.
B. Measure and record the temperature of the specimen: Measuring and recording the temperature of the urine specimen is important to ensure that the sample is fresh and has not been tampered with or substituted.
C. Pre-label the specimen container prior to collection: The container should be labeled after the specimen is collected to avoid mix-ups and to ensure accurate tracking.
D. Have the patient begin collecting the specimen mid-stream: The specimen for drug testing should typically be collected as a first-morning or a mid-stream sample to ensure accuracy, but this can vary based on specific protocols.