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. Subcutaneous: Subcutaneous injections are administered beneath the skin but are not considered topical.
B. Transdermal: Transdermal medications are applied directly to the skin and are absorbed through it, which is a form of topical administration.
C. Intramuscular: Intramuscular injections are given into the muscle tissue, not applied topically.
D. Percutaneous: Percutaneous administration involves drugs absorbed through the skin or mucous membranes, but the term is less specific compared to "transdermal" for topical medications.
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.