Deck 9: Introduction to the Soap Note

Question 1

Identify the statement that is NOT an appropriate response for the assessment section of the SOAP note.

A)The patient reports his pain level has increased from 4/10 to 7/10 since the treatment session on 3/9/17.
B)The patient was able to put on and button his sweater without any assistance today.
C)The patient was able to walk on an even surface over 20 feet today, as compared with 10 feet following last week's session.
D)The patient did not complain of any (B) leg spasms during the treatment session today.

Answer 1

The patient reports his pain level has increased from 4/10 to 7/10 since the treatment session on 3/9/17.

Question 2

What is the purpose of the assessment section in SOAP note documentation?

A)It helps determine the level of pain the patient is experiencing and how that pain will affect the patient's ability to perform the exercises.
B)It provides interpretation of the data content outlined in the plan of care.
C)It helps determine the patient's progress based on comparisons between the prior treatment sessions and the current treatment session.
D)It develops the plan of care for treatment for the patient's exercise program.

Answer 2

It helps determine the patient's progress based on comparisons between the prior treatment sessions and the current treatment session.

Question 3

What kind of data does the plan section contain?

A)Data that are recommended before the next treatment session
B)Data that include what happened during the treatment session
C)Data that contain the patient's medical history
D)Data that summarize the patient's history and objective information

Answer 3

Data that are recommended before the next treatment session

Question 4

Identify the statement that would be included in the subjective section of the SOAP note.

A)The patient plans on seeing his doctor next week for a follow-up visit.
B)The patient's wife states he still cannot pick up his clothes.
C)The patient reported he can run when he has been drinking.
D)The patient stated his pain level was a 5/10 following the last treatment session.

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?

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

Question 6

What is the PTA's specific responsibility when providing documentation in the objective section of the SOAP note?

A)Determine when the goals have been met and discharge should be addressed
B)Communicate any recommended changes in the plan of care
C)Document changes from the last treatment session to address functional progress in the plan of care related to improvements or regression in progress
D)Determine when the patient should receive additional services for OT

Question 7

Identify the statement that would be included in the assessment section of the SOAP note.

A)The patient plans on seeing his doctor next week for a follow-up visit for the (L) TKR.
B)The patient's wife states he cannot walk up the two steps to the house yet.
C)The patient reported he still cannot run after the treatment session is completed.
D)The patient reported his pain level was a 5/10 following the exercises today.

Question 8

What is the purpose of the objective section in SOAP note documentation?

A)It helps determine the level of pain the patient is experiencing.
B)It provides interpretation of the data content.
C)It helps determine how treatment is affecting function and whether the patient is progressing.
D)It develops the plan of care for treatment.

Question 9

What is the PTA's specific responsibility when providing documentation in the assessment section of the SOAP note?

A)Determine when the goals have been met and discharge should be addressed
B)Communicate any recommended changes in the plan of care
C)Help determine whether short-term goals have been met and the HEP has been successfully demonstrated before the session ends
D)Determine when the patient should receive additional services for OT services

Question 10

What is the purpose of the SOAP note rubric for the PTA student?

A)It helps determine which section of the SOAP note is most important.
B)It provides a method by which the PTA student can show how he or she completed the exercises within the plan of care.
C)It helps the student organize the sections of the SOAP note.
D)It develops the plan of care for treatment.

Question 11

Identify the statement that is NOT an appropriate response for the plan section of the SOAP note.

A)The patient reports his pain level has decreased from 9/10 to 5/10 since the treatment session on 3/9/17.
B)The patient was able to see his physician yesterday to obtain a new PT prescription.
C)The patient was fitted for (B) AFOs on Wednesday.
D)The patient did not see his OT yesterday because he was ill.

Question 12

Identify the statement that would be included in the plan section of the SOAP note.

A)The patient reports he will return to work tomorrow.
B)The patient's wife states he still cannot walk up two steps at home.
C)The patient reported he can run when he has been drinking.
D)The patient stated he has an appointment with his physician before his next treatment.

Question 13

Identify the statement that is NOT appropriate for the subjective section of the SOAP note.

A)The patient was able to put on and button his sweater without any aid prior to the treatment session today.
B)The patient will see the OT before the next treatment session next week.
C)The patient is now able to ambulate over 20 feet prior to the treatment session today, as compared with 10 feet following last week's session.
D)The patient has not had any leg spasms since the last treatment session.

Question 14

What is the purpose of the subjective section in SOAP note documentation?

A)It helps determine the level of pain the patient is experiencing.
B)It provides interpretation of the data content.
C)It helps determine the patient's care based on the relevance of the statements.
D)It develops the plan of care for treatment.

Question 15

Identify the statement that would be included in the objective section of the SOAP note.

A)The patient plans on seeing his doctor next week for a follow-up visit.
B)The patient's wife states he still cannot pick up his clothes.
C)The patient reported he can run approximately 50 feet since the evaluation.
D)The patient had AROM in shoulder flexion from 0° to 120º during today's session.

Question 16

What is the PTA's specific responsibility when providing documentation in the plan section of the SOAP note?

A)Determine when the goals have been met and discharge date should be set
B)Document the patient's pain level prior to treatment.
C)Determine when the patient should be referred for OT
D)Communicate any changes from the last treatment session to address functional progress in the plan of care

Question 17

Identify the statement that is NOT appropriate for the objective section of the SOAP note.

A)The patient reports his pain level has decreased from 9/10 to 5/10 since the treatment session on 3/9/17.
B)The patient was able to put on and button his sweater without any (A) today.
C)The patient was able to (I) walk on an even surface over 20 feet today using a normal gait pattern.
D)The patient did not complain of (B) leg spasms during the treatment session today.

Question 18

What kind of data does the objective section contain?

A)Data that are measurable and reproducible
B)Data that include what is going to happen next
C)Data that contain the patient's medical history
D)Data that summarize the patient's history and objective information

Question 19

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

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 20

What kind of data does the assessment section contain?

A)Data that summarize the subjective and objective sections
B)Data that include what is going to happen next
C)Data that contain the patient's medical history
D)Data that discuss the patient's history