Clinical Medical Assistant Certification Exam Practice Question
A patient calls the clinic and states that she has burning when urinating and a 2-day history of frequent urination. Which of the following must be documented in the progress note of this patient's electronic health record?
Correct Answer: A
Rationale: Documenting the date and time of the call is essential for tracking the patient's symptoms and ensuring timely follow-up, particularly in cases of potential urinary tract infections. This information establishes a timeline for the patient's condition and any subsequent actions taken.
The date of her last office visit (B) is useful but not critical for the immediate assessment of her current symptoms. The patient's date of birth (C) is important for identification but does not directly pertain to the current issue. The primary care physician's name (D) may be relevant for referrals but is not necessary for documenting the patient's immediate concerns. Recent laboratory results (E) are not applicable since the patient is reporting new symptoms without prior testing.
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