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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Related Questions
Correct Answer is B
Explanation
A. Right to change insurance companies during treatment: This is not part of the Patient's Bill of Rights. Changing insurance companies is subject to policy terms and regulations, not patient rights.
B. Right to refuse treatment: This is correct. The Patient’s Bill of Rights includes the right for patients to refuse treatment, even if that treatment is recommended by their healthcare provider.
C. Right to a timely visit: While timeliness is important, the Patient’s Bill of Rights does not specifically guarantee a timely visit.
D. Right to a specialist outside their network at no cost: This is not guaranteed under the Patient's Bill of Rights. Specialist visits, especially out-of-network, are typically governed by insurance coverage rules.
Correct Answer is A
Explanation
A. Offer the patient their elbow for guidance: Offering the elbow is a common and safe method of guiding patients with visual impairments, including presbyopia, because it allows the patient to follow the assistant's movements more easily.
B. Take the patient's hand. Taking the patient's hand might make the patient feel less secure and can lead to an imbalance. It is less effective than offering the elbow.
C. Lead the patient by their arm: Leading the patient by their arm can be uncomfortable and does not provide the same level of control as offering the elbow.
D. Guide the patient by holding their waist: Holding the waist is inappropriate as it invades personal space and might make the patient uncomfortable.
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