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. Restrain the patient: Restraining a patient during a seizure can cause injury and is not recommended.
B. Place a tongue blade in the patient's mouth: This is a myth and can cause harm. It is not safe or effective.
C. Move the patient to the floor in recovery position: If possible, gently guide the patient to the floor to prevent injury and place them in a recovery position after the seizure to keep the airway clear.
D. Initiate CPR on the patient: CPR is not needed unless the patient does not regain consciousness after the seizure or if there are other signs of respiratory or cardiac arrest.
Correct Answer is C
Explanation
A. Bland diet: A bland diet is used for gastrointestinal issues, not for hypertension management.
B. Clear liquid diet: A clear liquid diet is used temporarily post-surgery or during illness, not for managing hypertension.
C. Low-sodium diet: This is the correct diet plan for a patient with hypertension. Reducing sodium intake helps lower blood pressure and is a primary dietary recommendation for managing hypertension.
D. Low-protein diet: A low-protein diet is typically prescribed for patients with kidney disease, not hypertension.