Quiz on SOAP notes. Part One This part of the quiz will ask you to choose whether the data presented...

Quiz on SOAP notes

Part OneThis part of the quiz will ask you to choose whether the data presented is

subjective or objective information. These particular items are common problems for student NPs.

Read the data, make a choice, then left click again to discover the right answer.

Reminder: Subjective: what you can not verify by your own senses or hard data. Objective: what you can verify.

Many data points are covered to get you used to thinking about the difference. When you have had enough, scroll down to Part Two for the multiple choice quiz on other parts of the SOAP note.

If you have any questions about any part of this quiz consider bringing it up in a conference forum!

1) CBC result from last week

• Subjective• Objective

2) B/P done by the office RN


3) Urine dip done by office nurse


4) Pain when walking on Rt ankle


5) Limping


6) Pain with passive ROM of ankle


7) Dislikes vegetables


8) Hyponasal speech


9) Pain with deep breath


10) Pain with coughing


11) Pleural rub


12) Irregular Pulse


13) Palpitations


14) Dysuria


15) Muscle Pain (pt on Lipitor)


16) Ecchymoses


17) Periorbital Edema


18) Cool periphery


19) Rebound tenderness


20) Joint stiffness when getting up in the morning


21) Pitting edema


22) Unemployed


23) Poor hygeine


24) Divorced


25) Works with Asbestos


26) Flu vaccine reported as given on patient’s chart


27) Flu vaccine obtained at local flu clinic as reported by patient


28) Snoring reported by wife


29) Pruritis


30) Shortness of breath when getting onto exam table


31) Shortness of breath after walking one block


32) Mother had breast cancer


33) Eye discharge in inner canthus


34) CVA tenderness


35) Wakes several times every night


36) Dizziness


37) Positive Rhomberg


38) Snoring documented on sleep study report


39) Lives in a student dorm


40) Eats 3 meals a day and 2 snacks


Part Two: Multiple choice quiz

Read the question, decide on an answer, then Left Click to see the correct answer.

1) Follow up instructions should always include the following EXCEPT:

1. Return to clinic (RTC) in one week2. RTC if not improving in the specified time3. RTC prn4. What to do if there is a turn for the worse

2) Assessment/Analysis could include the following EXCEPT:

a. The chief symptomb. A wellness diagnosisc. A patient request for an antibioticd. A reference to a red flag symptom

3) Assessment/Analysis could include (choose the best answer):

a. A tentative diagnosisb. A statement of intentc. A general statement about the patientd. A summary of the subjective and

objective data

4) A diagnostic statement

a. should always be stated with certaintyb. is never really definitivec. needs to include a differential listd. should include a patient-focused goal

5) The Plan should always include the following:

a. Mention a referralb. A medicationc. A treatmentd. A follow-up plan

6) Considering the subjective and objective information helps the NP arrive at (choose the best answer)

a. A diagnosisb. A differential diagnosisc. A follow up pland. Diagnostic tests

7) Red flag signs or symptoms should be addressed either directly with a comment,

or indirectly with assessment data in which section(s) of the SOAP note?

a. The S and Ob. The A and Pc. The O, A, and Pd. The S, O, A and P

8) Which of the following items belong in the Subjective section?

a. The person appears unkemptb. The person’s breath smells fecalc. The person works as a plumberd. All of the above

9) A diagnostic statement includes (choose the best answer):

a. A statement about what the NP thinks it is and what it is not

b. A statement including leading differentials, if unsure

c. The status of the patient e.g. Stable, worse, improving, acute, etc.

d. All of the above

10) A SOAP note is

a. A way of organizing your thoughtsb. A way of documenting a patient encounter

that is understood by most health professionals

c. Provides a comprehensive picture of the patient encounter and reflects the practitioner’s thinking process

d. All of the above

11) It is important to indicate all of the following in a SOAP note EXCEPT:

a. To differentiate between an emergency and a routine visit

b. That the patient has been contacted to remind them about their follow-up appointment

c. Who is responsible to arrange diagnostic testsd. State the status of a condition e.g.

hypertension – controlled.

12) Functional Health Patterns include:

a. Reports of dysuria, headaches and nausea

b. Reports of falls, insomnia, and sedentary lifestyle

c. Current weight, height and LMPd. Reports of itchy skin, fever, chills and

palpitations

Functional Health Patterns are subjective information

13) The Review of Systems (ROS) is

a) Objective informationb) Subjective informationc) Not part of a SOAP noted) The same as the physical exam

14) Allergies, immunizations and medications go in what section of

the SOAP note?a. The Sb. The Oc. The Ad. The P

Generally this information is reported to you by the patient. If you have seen hives as a result of an antibiotic, this would be objective info. If you had given the immunization (or someone in your office gave it) that would also be objective. Medications as reported by the patient are subjective and different from thinking about what they are supposed to be on.Be careful not to equate subjective information as untrue information. If a patient reports an allergy then it is prudent to take that info as a fact.

The End

January 2012Centre for Health Studies

Nurse Practitioner Program

Quiz on SOAP notes. Part One This part of the quiz will ask you to choose whether the data presented...

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