Which of the following should a medical assistant note in a patient's electronic health record?
The patient reports the receptionist was rude to them.
The patient states that there is an error on their bill.
The patient states their insurance might be changing soon.
The patient reports they recently developed a strawberry allergy.
The Correct Answer is D
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. To record the patient's demographic information: Demographic information is recorded in other sections of the medical record, not in a flow sheet.
B. To record the patient's name, insurance, and next of kin: This information is also found in other sections of the medical record, not typically in a flow sheet.
C. To record nursing plans and postoperative care: Nursing plans and postoperative care are documented in different sections, such as care plans or progress notes, not in a flow sheet.
D. To record vital signs, weight, I&O, and doctor visits: Flow sheets or electronic graphs are used to track and visualize ongoing patient data, including vital signs, weight, intake and output (I&O), and doctor visits.
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