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. Instruct the patient to collect the specimen and return it to the laboratory: For a valid drug screening, the specimen should be collected in the presence of a medical professional to prevent tampering.
B. Measure and record the temperature of the specimen: Measuring and recording the temperature of the urine specimen is important to ensure that the sample is fresh and has not been tampered with or substituted.
C. Pre-label the specimen container prior to collection: The container should be labeled after the specimen is collected to avoid mix-ups and to ensure accurate tracking.
D. Have the patient begin collecting the specimen mid-stream: The specimen for drug testing should typically be collected as a first-morning or a mid-stream sample to ensure accuracy, but this can vary based on specific protocols.
Correct Answer is C
Explanation
A. Patient was advised to choose foods low in fiber: This may not be appropriate for all patients; dietary recommendations should be personalized and specific.
B. Patient was advised to eliminate lactose in their diet: This is only applicable if lactose intolerance or a similar condition is identified.
C. Patient was provided with a MyPlate handout: Documenting the provision of educational materials such as a MyPlate handout shows that preventative dietary guidelines were shared with the patient.
D. Patient was provided a sodium reference guide: While useful, it does not encompass the full range of preventative dietary guidelines typically covered in an annual exam.