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Question
if ms. garcia tells the medical assistant she has been suffering from a headache for the last week, how should this be noted on her medical record?
a. ms. garda states, \ive had a headache every day for the last week.\
b. ms. garcia complains of having a headache every day for the last week.
c. ms. garcias complaint is a headache.
d. the purpose of ms. garcias visit is to report an ongoing headache.
In medical records, it is best to record the patient's exact words. Option a quotes Ms. Garcia directly, providing the most accurate and detailed account of her statement about the headache duration.
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A. Ms. Garda states, "I've had a headache every day for the last week."