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. Sitting behind a desk and looking at the computer: This posture may appear distant and disinterested, as it creates a physical barrier and lacks engagement.
B. Sitting on the edge of a chair and leaning forward: This body language conveys attentiveness and engagement, indicating care and interest in the conversation with the patient.
C. Standing across the room. Standing across the room can seem impersonal and distant, which may not effectively communicate care and interest.
D. Standing over the patient: Standing over the patient can be intimidating and may convey dominance rather than care and support.
Correct Answer is A
Explanation
A. Allergies:Allergy information is crucial for preventing adverse reactions to medications and treatments, so it often appears as a pop-up alert in electronic health records (EHRs) to ensure that healthcare providers are aware of any potential risks.
B. Illnesses:Illnesses are typically documented in the patient's history, but they do not usually trigger a pop-up alert unless they are related to specific critical conditions or current treatment concerns.
C. Hospitalizations:Hospitalization history is important but is typically found in the patient's medical history section rather than as an immediate alert in the EHR.
D. Surgeries:Surgical history is generally noted in the patient’s medical history, and while important, it does not usually appear as a pop-up alert unless it directly impacts current treatment.