Patient CareCâu 20 / 100
During intake, a patient says, "My chest has been hurting since yesterday morning." How should the medical assistant document the chief complaint?
a.Chief complaint: "My chest has been hurting since yesterday morning" - recorded in the patient's own words
b.Chief complaint: probable angina pectoris
c.Chief complaint: patient seems anxious about the heart
d.Chief complaint: rule out myocardial infarction
Giải thích
The chief complaint is charted concisely in the patient's own words because it is subjective data, and quoting avoids interpretation. Naming angina or myocardial infarction is a diagnosis, which is outside the medical assistant's scope. Describing the patient as anxious is a subjective judgment rather than what the patient actually reported.
Luyện miễn phí toàn bộ 100 câu hỏi — không cần đăng ký.
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