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 D
Explanation
A. Human hair: Human hair is not considered potentially infectious material under the Bloodborne Pathogens Standard.
B. Sweat: Sweat is not classified as potentially infectious material because it does not typically contain bloodborne pathogens.
C. Normal saliva: Normal saliva is not classified as potentially infectious material; however, saliva can be considered potentially infectious if it is visibly contaminated with blood.
D. Septic wound: A septic wound contains pus and is considered potentially infectious material because it can contain pathogens.
Correct Answer is B
Explanation
A. C-reactive protein (CRP): CRP is typically tested using a serum sample collected in a gold or red-top tube, not a light blue tube.
B. Partial thromboplastin time (PTT): PTT is a coagulation test that requires a light blue top tube containing sodium citrate, which acts as an anticoagulant. This tube is specifically used for coagulation studies.
C. Glucose: Glucose levels are commonly measured using a gray-top tube containing sodium fluoride to inhibit glycolysis, not a light blue tube.
D. Lactate: Lactate levels are typically measured using a gray-top tube or green-top tube, depending on the specific protocol, not a light blue tube.