Which of the following should a medical assistant plan to assess at a well-child visit for a 2-month-old infant?
Snellen chart testing
Growth chart mapping
Autism spectrum disorder screening
D Denver II Developmental Screening Test
The Correct Answer is B
A. Snellen chart testing: Snellen chart testing is used to assess visual acuity in older children, not infants.
B. Growth chart mapping: This is correct. Growth chart mapping is a standard assessment for infants to monitor their physical development.
C. Autism spectrum disorder screening: Autism screening typically begins around 18 months, not at 2 months of age.
D. Denver II Developmental Screening Test: The Denver II is used to assess developmental milestones in children, but it is typically performed later, not at 2 months.
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Correct Answer is A
Explanation
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.
Correct Answer is D
Explanation
A. The patient reports the receptionist was rude to them. This is not relevant to the patient’s medical care and should not be documented in the health record.
B. The patient states that there is an error on their bill. Billing issues are not related to the clinical care of the patient and should not be documented in the health record.
C. The patient states their insurance might be changing soon. This is administrative information and does not pertain to the clinical aspect of the patient’s care.
D. The patient reports they recently developed a strawberry allergy. This is relevant medical information that could affect the patient’s treatment and should be documented in the health record.