Question

In which section of the EMR should you document the following statement from a patient and how would you document it?

"no, I haven't had any shortness of breath or felt my heart racing"

Option 1: Review of Systems (ROS)
Option 2: Assessment
Option 3: Treatment Plan
Option 4: Chief Complaint

Answer 1

The statement should be documented in the Review of Systems (ROS) section with the exact statement and any relevant details.

Step-by-step explanation:

The statement from the patient, "no, I haven't had any shortness of breath or felt my heart racing", should be documented in the Review of Systems (ROS) section of the EMR (Electronic Medical Record).

To document it, you would note the patient's statement exactly as they said it, using quotation marks. You can also include any relevant details such as the date and time of the statement, and the patient's name. For example, you could write: "Patient stated on [date] at [time]: 'no, I haven't had any shortness of breath or felt my heart racing'. - [Patient's Name]".