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. Apply ice to the wound: Ice can help with swelling but is not the first-line treatment for controlling bleeding.
B. Lower the affected leg: Elevating the leg is usually recommended, not lowering it, to help control bleeding.
C. Press down firmly over a pressure point: Applying firm pressure to a pressure point can help control hemorrhage by reducing blood flow to the area.
D. Cauterize the wound from the edges to center: Cauterization is not typically a first response in an emergency setting; it is usually performed in a controlled medical environment.
Correct Answer is D
Explanation
A. The date the patient's illness ended: The form does not require the end date of the patient’s illness, but the date of service and diagnosis are needed.
B. The patient's filing limits: Filing limits are set by the insurance carrier and are not required information on the CMS-1500 form.
C. The patient's previous account balance: The previous account balance is not required on the claim form; this form is for billing current services.
D. The patient's insurance identification number: The patient's insurance identification number is required to process the claim with the correct insurance provider.