In which of the following locations on a paper health record should a medical assistant document a patient's temperature, pulse, and respirations?
Subjective
Objective
Assessment
Plan
The Correct Answer is B
A. Subjective: The subjective section contains information reported by the patient, such as symptoms and experiences, not objective measurements.
B. Objective: Objective measurements, such as vital signs (temperature, pulse, respirations), are documented in the objective section of the health record because they are measurable and observable data.
C. Assessment: The assessment section includes the healthcare provider’s interpretation of the data and diagnosis, not the actual measurements.
D. Plan: The plan section details the proposed treatment or management strategy, not the recorded measurements.
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Related Questions
Correct Answer is C
Explanation
A. Consent form: A consent form is a document that gives permission for medical procedures or treatments and is not the same as a superbill.
B. Assignment of benefits: Assignment of benefits is a document that allows the insurance company to pay the provider directly, not a billing form used to summarize charges.
C. Encounter form: A superbill is also known as an encounter form. It details the services provided, diagnosis codes, and charges for a patient’s visit.
D. Advanced beneficiary notice: An advanced beneficiary notice informs patients about services that Medicare may not cover and is not related to billing or charges.
Correct Answer is C
Explanation
Correct answer: C
A. A steady pulse rhythm in a 16-year-old male patient. A steady pulse rhythm is normal and within the expected range for a 16-year-old male.
B. A pulse rate of 68/min in a 35-year-old female patient: A pulse rate of 68/min is within the normal resting heart rate range for a 35-year-old female (60-100/min).
C. A bounding pulse volume in a 56-year-old male patient: A bounding pulse volume indicates an unusually strong pulse, which could be a sign of hypertension or other circulatory issues and should be reported.
D. A pulse rate of 120/min in a 22-year-old female patient: A pulse rate of 120/min is above the normal range (tachycardia) and should be reported, as it could indicate a cardiac or systemic problem.
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