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 C
Explanation
A. Apply ice to the wound: Ice can help with swelling but is not the first-line treatment for controlling bleeding.
B. Lower the affected leg: Elevating the leg is usually recommended, not lowering it, to help control bleeding.
C. Press down firmly over a pressure point: Applying firm pressure to a pressure point can help control hemorrhage by reducing blood flow to the area.
D. Cauterize the wound from the edges to center: Cauterization is not typically a first response in an emergency setting; it is usually performed in a controlled medical environment.
Correct Answer is A
Explanation
A. Deflate the cuff slowly until the last sound is heard. The diastolic reading is determined when the last sound (Korotkoff sound) is heard as the cuff is deflated.
B. Listen for the first sound through the stethoscope: The first sound corresponds to the systolic reading, not the diastolic.
C. Document the reading when the gauge needle jumps: The gauge needle jump is not a reliable indicator of blood pressure readings.
D. Inflate the cuff to at least 180 mm Hg, deflate the cuff slowly, and listen for the first sound: Inflating to 180 mm Hg is unnecessary and might cause discomfort; also, the first sound is the systolic reading, not the diastolic
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