Question 1

Identify the statement that is appropriate for the plan section of the SOAP note.

Accepted Answer

A) The patient will be treated 1x/week until discharge to home with follow-up through the home health agency. 
B) The patient was able to put on and button his sweater without any aids today. 
C) The patient was able to ambulate over 20 feet today as compared with 10 feet following last week's session. 
D) The patient did not complain of any leg spasms during the treatment session today. A

Question 2

Identify the information that would be incorrect to include in the plan section of the SOAP note.

Accepted Answer

A) The date when the patient's next session will be scheduled 
B) The date when the next PT supervisory visit will be scheduled 
C) Information related to the patient's pain level and responses from last treatment session 
D) The number of treatment sessions that the patient has before the next evaluation C

Question 3

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

Accepted Answer

A) Will walk patient on grass and curbs this PM per PT's goal in initial evaluation. 
B) Patient states he can get into and out of his car (I) to drive. 
C) Patient completed SLR exercises, 10x, 3 sets, supine, independently. 
D) Patient's husband wants her to be able to go out to dinner like they used to do. A

Question 4

What type of plan information should be included in the initial evaluation by the PT?

Accepted Answer

A) It should be related to the outcomes, including the frequency and duration. 
B) It should determine how the patient's pain level will be measured. 
C) It should include measurements of the patient's range of motion and muscle strength. 
D) It should include the family's wishes and not the patient's.

Question 5

What kind of data does the plan section of the SOAP note contain?

Accepted Answer

A) Data that can be reproduced or confirmed 
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 6

What is one of the most important concepts to address in the plan section of the SOAP note?

Accepted Answer

A) Interpretation of the data 
B) Adapting the goals and outcomes within the plan of care 
C) Any equipment that needs to be addressed before the next treatment session 
D) Continuing to focus on the past medical history

Question 7

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

Accepted Answer

A) Determine when the goals have been met and discharge should be addressed 
B) Communicate any recommended changes the PTA has made in the plan of care 
C) Communicate any recommendations for additional services to the PT 
D) Determine when the patient should receive additional services for speech

Question 8

Identify the parameters that should be included in the plan section of the SOAP note.

Accepted Answer

A) The patient's response to the last treatment session 
B) Measurement comparisons from the initial evaluation and the current treatment session 
C) The goals to be accomplished in the plan of care 
D) Referral to another discipline, strength measurements, and stride length

Question 9

Why is it important to predict the patient's progress in the plan section of the SOAP note?

Accepted Answer

A) This information helps determine how much pain the patient is experiencing. 
B) This information will help the therapist determine whether the patient is improving. 
C) This information is not necessary in the plan section of the SOAP note. 
D) This information will help determine what services the patient might need for future progress.

Question 10

In SOAP note documentation, what is the PT's documentation goal in the plan section for the initial evaluation?

Accepted Answer

A) Evaluation of the patient's functional level 
B) Development of the goals in the plan of care 
C) Assessment of the patient's ability to perform ADLs 
D) Interpretation of the patient's signs and symptoms

Question 11

A PT and a PTA discuss changes to a patient's expected goals and plan of care.Which statement best demonstrates how such changes should be documented in the plan section of the SOAP note?

Accepted Answer

A) The patient will ambulate (I) 200 ft.with FWW at the end of 3 weeks. 
B) The patient stated his or her pain level was an 8/10 prior to treatment today. 
C) The patient completed AROM in (L) shoulder flex.(I) 10x, 3 sets. 
D) The patient performed quad sets 10x, 3 sets.

Question 12

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

Accepted Answer

A) The patient stated his pain level was a 5/10 following the treatment session. 
B) The patient can now use his FWW walker to ambulate to his mailbox. 
C) The patient was able to transfer from the bed to the w/c 2x with SBA. 
D) The patient plans on seeing his doctor next week for a follow-up visit.

Question 13

What is the most important part of an outcome or goal in the plan section of a SOAP note?

Accepted Answer

A) Using a noun to determine what the patient has done since the last session 
B) Using adjectives to describe how the patient will complete a skill 
C) Using verbs, in the future tense, to describe what will happen next 
D) Using an adverb to describe how well the patient performed a skill

Question 14

Who is responsible for changing the repetitions/sets during the treatment session when there is a lack of progress in the treatment plan?

Accepted Answer

A) PT and PTA 
B) PT 
C) Patient 
D) PT and patient

Question 15

It is important to identify a lack of progress in the treatment plan and for the PTA to make suggestions for changes.Identify the correct example of such a response.

Accepted Answer

A) Patient could not use a quad cane to walk from house to mailbox within 2 weeks, as outlined in the POC.PTA will contact PT before next visit to address inability to reach prescribed goal. 
B) Patient completed AROM in hip flex.to 90º as compared with initial evaluation of 120º.PTA will communicate change to PT by next visit. 
C) Patient reported that his pain level has increased from the last session from 7/10 to 9/10 because of poor posture.PTA will contact PT regarding change in pain level and revision of POC. 
D) There has been an increase in core stability, with patient able to sit (I) for 10 sec compared with IE of 5 sec with SBA at EOB.

Question 16

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

Accepted Answer

A) It helps determine the level of pain the patient is experiencing. 
B) It provides interpretation of the data content. 
C) It outlines what interventions are proposed for the patient. 
D) It develops the plan of care for treatment.

Question 17

General plan data provide an assumption of future activities that the patient will complete based on the goals set up through the initial evaluation by the PT.However, the student PTA often makes too general a statement that is not appropriate for this section.Identify the incorrect statement that the PTA might use for the plan section.

Accepted Answer

A) Patient tolerated treatment well, without fatigue today, and plan of care will continue. 
B) Patient has made good progress and can ascend two steps. 
C) Patient able to demonstrate increased PROM in all shoulder motions (
B) . 
D) Patient performed a correct return demonstration of HEP.

Question 18

When writing information in the plan section of the SOAP note, why is it important to provide sufficient information?

Accepted Answer

A) Another therapist can reproduce the treatment session if the first therapist is absent. 
B) The therapist can determine whether the patient is progressing toward the goals outlined in the evaluation over the time period outlined. 
C) The therapist can answer all of the patient's questions about each treatment session. 
D) The patient can tell his or her family what the treatment session included.

Question 19

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

Accepted Answer

A) Patient demonstrated an antalgic gait pattern while walking into the TX session. 
B) Patient demonstrated frequent wt.shifts while sitting 15 min prior to TX. 
C) Patient walks with a shuffling gait pattern with (R) hip, knee, and ankle in flexion. 
D) Patient will return to physician for re-evaluation following next PT visit.

Question 20

Under what circumstances should a PTA communicate the need for re-evaluation for the discharge process to the supervising PT?

Accepted Answer

A) When the patient has met all the goals within the plan of care but can progress further 
B) When the patient is noncompliant with the program because of illness 
C) When the patient's insurance company has agreed to two more visits 
D) When the patient is no longer making progress within the plan of care and has reached a plateau

Exam 13: What Is the Plan and Why Is It Important