Question 1

From the statements provided, identify the correct subjective statement.

Accepted Answer

A) The patient reported that he went bowling last night and met a nice girl. 
B) The patient reported that he played chess with his grandmother yesterday and she won. 
C) The patient reported that his pain level was 6/10 prior to treatment today. 
D) The patient reported that his pain level was 3/10 in his right shoulder prior to treatment today. 
A) The patient reported that he went bowling last night and met a nice girl. 
B) The patient reported that he played chess with his grandmother yesterday and she won. 
C) The patient reported that his pain level was 6/10 prior to treatment today. 
D) The patient reported that his pain level was 3/10 in his right shoulder prior to treatment today. D

Question 2

What type of listening skill provides information simply by overhearing a conversation related to a patient?

Accepted Answer

A) Passive 
B) Courteous 
C) Exploratory 
D) Appreciative 
A) Passive 
B) Courteous 
C) Exploratory 
D) Appreciative A

Question 3

Why is it important to provide documentation related to the patient's level of pain?

Accepted Answer

A) It can help patients determine whether the pain will get better. 
B) It provides a measurement to help determine whether treatment is helping or hindering the patient's progress. 
C) It provides the therapist with a measure of how the patient is progressing in the plan of care. 
D) It helps the physician determine whether the patient is getting worse and the diagnosis needs to be re-evaluated. 
A) It can help patients determine whether the pain will get better. 
B) It provides a measurement to help determine whether treatment is helping or hindering the patient's progress. 
C) It provides the therapist with a measure of how the patient is progressing in the plan of care. 
D) It helps the physician determine whether the patient is getting worse and the diagnosis needs to be re-evaluated. B

Question 4

Identify the correct statement that indicates when to use a quote from a patient when documenting in the subjective section of the SOAP note.

Accepted Answer

A) To document a patient's attitude toward therapy 
B) To document the patient's dietary habits 
C) To document the patient's activities with friends 
D) To document the patient's ability to look for a job 
A) To document a patient's attitude toward therapy 
B) To document the patient's dietary habits 
C) To document the patient's activities with friends 
D) To document the patient's ability to look for a job

Question 5

What is specific to a patient; modified or affected by his or her personal views, experience, or background; and arises out of or is identified by means of one's perception of one's own states and processes?

Accepted Answer

A) Personal history 
B) Assessment information 
C) Patient's goals and outcomes 
D) Subjective information 
A) Personal history 
B) Assessment information 
C) Patient's goals and outcomes 
D) Subjective information

Question 6

What type of listening technique is used in response to a specific question asked of a patient?

Accepted Answer

A) Analytic listening 
B) Directed listening 
C) Exploratory listening 
D) Appreciative listening 
A) Analytic listening 
B) Directed listening 
C) Exploratory listening 
D) Appreciative listening

Question 7

Identify the correct subjective statement.

Accepted Answer

A) The patient told me he had oatmeal for breakfast. 
B) The patient stated that he played poker with his friends last night. 
C) The patient reported that he was able to walk 100′ to the mailbox this morning without his walker. 
D) The patient reported that he had an argument with his mother-in-law again. 
A) The patient told me he had oatmeal for breakfast. 
B) The patient stated that he played poker with his friends last night. 
C) The patient reported that he was able to walk 100′ to the mailbox this morning without his walker. 
D) The patient reported that he had an argument with his mother-in-law again.

Question 8

What information should be included in the subjective section of the SOAP note?

Accepted Answer

A) Information that describes what will happen next 
B) Information that provides a summary of subjective and objective information 
C) Information that is easily reproducible and demonstrable 
D) Information about the patient's past medical history 
A) Information that describes what will happen next 
B) Information that provides a summary of subjective and objective information 
C) Information that is easily reproducible and demonstrable 
D) Information about the patient's past medical history

Question 9

If the patient cannot verbally communicate with you, how can you determine what his or her pain level might be prior to, during, or following treatment?

Accepted Answer

A) The patient can point to a symbol that identifies his or her pain level. 
B) The patient does not have to report his or her pain level if it cannot be communicated verbally. 
C) A family member or the caregiver can provide the pain level for the patient. 
D) The patient can use Morse code to tap out his or her pain level. 
A) The patient can point to a symbol that identifies his or her pain level. 
B) The patient does not have to report his or her pain level if it cannot be communicated verbally. 
C) A family member or the caregiver can provide the pain level for the patient. 
D) The patient can use Morse code to tap out his or her pain level.

Question 10

Identify the correct subjective statement.

Accepted Answer

A) The patient reported that he watched the Super Bowl yesterday. 
B) The patient stated that he was able to sit for 15 minutes to watch TV last night without increasing pain. 
C) The patient reported his pain was 7/10 today, much worse than prior to the last session. 
D) The patient reported he was able to walk without his FWW today. 
A) The patient reported that he watched the Super Bowl yesterday. 
B) The patient stated that he was able to sit for 15 minutes to watch TV last night without increasing pain. 
C) The patient reported his pain was 7/10 today, much worse than prior to the last session. 
D) The patient reported he was able to walk without his FWW today.

Question 11

Identify the correct written subjective statement regarding the patient's pain level.

Accepted Answer

A) The patient stated that the pain in his (R) hip was 8 following the last treatment session. 
B) The patient reported that the pain in her (L) shoulder was 7/10 prior to treatment today. 
C) The patient stated that he had no pain in his leg today. 
D) The patient reported that his wife was a pain in the neck. 
A) The patient stated that the pain in his (R) hip was 8 following the last treatment session. 
B) The patient reported that the pain in her (L) shoulder was 7/10 prior to treatment today. 
C) The patient stated that he had no pain in his leg today. 
D) The patient reported that his wife was a pain in the neck.

Question 12

We determine a patient's pain level using many tools.What is the most commonly used tool to assess this subjective response?

Accepted Answer

A) Body Drawing 
B) PLE 
C) Pain Profile 
D) VRS 
A) Body Drawing 
B) PLE 
C) Pain Profile 
D) VRS

Question 13

Appropriate listening skills are imperative in patient documentation.Identify the word that means using listening skills to determine specific types of information (i.e., pain, lifestyle, fears).

Accepted Answer

A) Attentive 
B) Passive 
C) Analytic 
D) Exploratory 
A) Attentive 
B) Passive 
C) Analytic 
D) Exploratory

Question 14

It is important when discussing subjective information from a patient, caregiver, relative, or others that the information given meets certain guidelines.Choose the phrase that best describes those guidelines.

Accepted Answer

A) Can be recorded by anyone 
B) Does not need to be recorded in the daily progress note 
C) Must be relevant 
D) Must be a direct quote 
A) Can be recorded by anyone 
B) Does not need to be recorded in the daily progress note 
C) Must be relevant 
D) Must be a direct quote

Question 15

Identify the correct subjective statement.

Accepted Answer

A) "My left hip hurts because I fell last night." 
B) "I drank too much last night and have a hangover." 
C) "I took my driver's license exam this morning." 
D) "My brother is coming to visit this week." 
A) "My left hip hurts because I fell last night." 
B) "I drank too much last night and have a hangover." 
C) "I took my driver's license exam this morning." 
D) "My brother is coming to visit this week."

Question 16

Subjective information includes specific types of information related to the patient.Choose the statement that would be included in this part of the documentation.

Accepted Answer

A) The patient was able to ambulate (I) 20 feet using a front-wheeled walker. 
B) The patient will be referred to OT for a hand splint. 
C) The patient reported his pain level prior to treatment was a 6/10 on the VRS. 
D) The patient will continue to be seen 2x/week. 
A) The patient was able to ambulate (I) 20 feet using a front-wheeled walker. 
B) The patient will be referred to OT for a hand splint. 
C) The patient reported his pain level prior to treatment was a 6/10 on the VRS. 
D) The patient will continue to be seen 2x/week.

Question 17

When writing subjective information, it is important to use relevant verbs when describing the patient's responses.Choose the statement that uses the words to meet this criterion.

Accepted Answer

A) The patient reports that his wife is always nagging him. 
B) The patient states that he would like to be able to go drinking with his buddies again. 
C) The patient stated that she wants to be able to walk up and down the two steps in front of her house. 
D) The patient is eating all foods by mouth. 
A) The patient reports that his wife is always nagging him. 
B) The patient states that he would like to be able to go drinking with his buddies again. 
C) The patient stated that she wants to be able to walk up and down the two steps in front of her house. 
D) The patient is eating all foods by mouth.

Question 18

What type of listening technique may provide information regarding the patient that is not a direct response to a question asked of the patient?

Accepted Answer

A) Attentive listening 
B) Exploratory listening 
C) Passive listening 
D) Courteous listening 
A) Attentive listening 
B) Exploratory listening 
C) Passive listening 
D) Courteous listening

Question 19

What type of listening technique demonstrates respect for the patient?

Accepted Answer

A) Attentive listening 
B) Appreciative listening 
C) Exploratory listening 
D) Courteous listening 
A) Attentive listening 
B) Appreciative listening 
C) Exploratory listening 
D) Courteous listening

Question 20

What type of subjective information about the patient could be included in an initial evaluation?

Accepted Answer

A) Patient's level of independence in combing hair 
B) Patient's initial pain level 
C) Patient's ability to ambulate independently on even ground 
D) Patient's ability to take a shower without assistance 
A) Patient's level of independence in combing hair 
B) Patient's initial pain level 
C) Patient's ability to ambulate independently on even ground 
D) Patient's ability to take a shower without assistance

From the statements provided, identify the correct subjective statement.

What type of listening skill provides information simply by overhearing a conversation related to a patient?

Why is it important to provide documentation related to the patient's level of pain?

Identify the correct statement that indicates when to use a quote from a patient when documenting in the subjective section of the SOAP note.

What is specific to a patient; modified or affected by his or her personal views, experience, or background; and arises out of or is identified by means of one's perception of one's own states and processes?

What type of listening technique is used in response to a specific question asked of a patient?

Identify the correct subjective statement.

What information should be included in the subjective section of the SOAP note?

If the patient cannot verbally communicate with you, how can you determine what his or her pain level might be prior to, during, or following treatment?

Identify the correct subjective statement.

Identify the correct written subjective statement regarding the patient's pain level.

We determine a patient's pain level using many tools.What is the most commonly used tool to assess this subjective response?

Appropriate listening skills are imperative in patient documentation.Identify the word that means using listening skills to determine specific types of information (i.e., pain, lifestyle, fears).

It is important when discussing subjective information from a patient, caregiver, relative, or others that the information given meets certain guidelines.Choose the phrase that best describes those guidelines.

Identify the correct subjective statement.

Subjective information includes specific types of information related to the patient.Choose the statement that would be included in this part of the documentation.

When writing subjective information, it is important to use relevant verbs when describing the patient's responses.Choose the statement that uses the words to meet this criterion.

What type of listening technique may provide information regarding the patient that is not a direct response to a question asked of the patient?

What type of listening technique demonstrates respect for the patient?

What type of subjective information about the patient could be included in an initial evaluation?

Introduction to Documentation

The World Health Organization and the International Classification of Functioning, Disability and Health

Demystifying the Icd-10 Coding System

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

How Does Documentation Relate to Patient Issues

Legal and Ethical Issues Related to Documentation

Introduction to the Soap Note

What Is Objective Data and Why Is It Important

What Is Assessment Data and Why Is It Important

What Is the Plan and Why Is It Important

Putting the Pieces Together

Filters

Exam 10: What Is Subjective Data and Why Is It Important

From the statements provided, identify the correct subjective statement.

What type of listening skill provides information simply by overhearing a conversation related to a patient?

Why is it important to provide documentation related to the patient's level of pain?

Identify the correct statement that indicates when to use a quote from a patient when documenting in the subjective section of the SOAP note.

What is specific to a patient; modified or affected by his or her personal views, experience, or background; and arises out of or is identified by means of one's perception of one's own states and processes?

What type of listening technique is used in response to a specific question asked of a patient?

Identify the correct subjective statement.

What information should be included in the subjective section of the SOAP note?

If the patient cannot verbally communicate with you, how can you determine what his or her pain level might be prior to, during, or following treatment?

Identify the correct subjective statement.

Identify the correct written subjective statement regarding the patient's pain level.

We determine a patient's pain level using many tools.What is the most commonly used tool to assess this subjective response?

Appropriate listening skills are imperative in patient documentation.Identify the word that means using listening skills to determine specific types of information (i.e., pain, lifestyle, fears).

It is important when discussing subjective information from a patient, caregiver, relative, or others that the information given meets certain guidelines.Choose the phrase that best describes those guidelines.

Identify the correct subjective statement.

Subjective information includes specific types of information related to the patient.Choose the statement that would be included in this part of the documentation.

When writing subjective information, it is important to use relevant verbs when describing the patient's responses.Choose the statement that uses the words to meet this criterion.

What type of listening technique may provide information regarding the patient that is not a direct response to a question asked of the patient?

What type of listening technique demonstrates respect for the patient?

What type of subjective information about the patient could be included in an initial evaluation?

Introduction to Documentation

The World Health Organization and the International Classification of Functioning, Disability and Health

Demystifying the Icd-10 Coding System

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

How Does Documentation Relate to Patient Issues

Legal and Ethical Issues Related to Documentation

Introduction to the Soap Note

What Is Objective Data and Why Is It Important

What Is Assessment Data and Why Is It Important

What Is the Plan and Why Is It Important

Putting the Pieces Together

Filters