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. Implied consent: Implied consent is typically used in emergency situations where verbal or written consent cannot be obtained and is not suitable for elective procedures like a colonoscopy.
B. Informed consent: For a colonoscopy, which is an invasive procedure, informed consent is required. This involves providing the patient with detailed information about the procedure, its risks, benefits, and alternatives.
C. Prior authorization: Prior authorization is related to insurance coverage and is not typically obtained by the medical assistant; it is usually handled by the billing department or insurance coordinator.
D. Immunization records: Immunization records are not required for a colonoscopy; they are more relevant for vaccinations and certain other procedures.
Correct Answer is D
Explanation
A. Remove dental plates before the procedure. Dental plates do not interfere with a mammogram, so removing them is unnecessary.
B. Do not eat or drink anything for 4 hr before the procedure. There are no dietary restrictions required before a mammogram, so this instruction is not necessary.
C. An IV will be started before the procedure. An IV is not required for a mammogram, which is a non-invasive imaging procedure.
D. Do not apply any deodorant before the procedure. Patients are advised not to apply deodorant, lotions, or powders before a mammogram because these products can show up as artifacts on the mammogram images, potentially leading to misinterpretation.