Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalEasy
A medical assistant is documenting a patient's chief complaint. The patient states, "I've had a terrible headache for three days, and nothing helps." Which of the following is the most appropriate way to document this in the patient's chart?
- APatient states, 'I've had a terrible headache for three days, and nothing helps.'
- BPatient complains of severe headache for 3 days, unresponsive to treatment.
- CHeadache, 3 days duration, severe, intractable.
- DPatient appears to be in severe pain due to headache.
Show answer & explanationAnswer & explanation
Correct answer: A. Patient states, 'I've had a terrible headache for three days, and nothing helps.'
When documenting a chief complaint, it is best practice to record the patient's exact words in quotation marks. This preserves the subjective nature of the complaint and avoids misinterpretation or bias from the medical assistant.
Why the other options are wrong
- B. This paraphrases the patient's statement, introducing the MA's interpretation and potentially losing nuance.
- C. This is too brief and uses medical jargon that might not fully convey the patient's subjective feeling.
- D. This is an observation by the MA, not the patient's chief complaint, and should be documented separately if relevant.
Documenting Chief Complaint
The practice of recording the patient's primary reason for seeking medical attention in their own words.
- Should be verbatim, in quotation marks.
- Reflects the patient's subjective experience.
- Avoids interpretation or bias by the healthcare professional.
Memory trick: Patient's words, always quotes for true reports.