Free AAMA Certified Medical Assistant (CMA) Practice Question
A patient's description of the onset and character of pain, location, associated symptoms, and aggravating or relieving factors are all important elements that should be documented in the present illness section of the medical record.
The subjective data section of a medical record is essential for capturing the patient's personal experience of their illness. It includes the patient's account of the history and course of the present illness which is crucial for establishing a diagnosis. Accurate documentation must encompass all elements of the patient's experience of their health concerns, including details like when the problem started, the nature of the pain (sharp, dull, throbbing, etc.), the specific location, what other symptoms they are experiencing, and what factors make these symptoms better or worse. This nuanced information guides clinical decision-making and personalized patient care.
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This question's topic:
AAMA Certified Medical Assistant (CMA) /
Clinical Competency
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