Question 1

Even though SOAP note documentation provides an easy method for organizing patient information, there are some problems that occur with its use.Identify a common complaint expressed when using a SOAP note format.

Accepted Answer

A) It focuses on the patient's impairments. 
B) It does not record the patient's progress. 
C) It does not delineate the plan of care. 
D) It does not address goals and outcomes. A

Question 2

Identify the statement that would be included in the objective 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 reported that he can use his walker to get to his car now. 
C) The patient was able to perform AAROM to (R) shoulder, flex.0º to 180º, 10 reps, 3 sets. 
D) The patient plans on seeing his doctor next week for a follow-up visit. C

Question 3

What kind of data does the objective section contain?

Accepted Answer

A) Data that summarize the patient's history and assessment 
B) Data that include what is going to happen 
C) Data that contain the patient's medical history 
D) Data that can be reproduced or confirmed D

Question 4

What type of objective information should be included in the initial evaluation?

Accepted Answer

A) ROM and strength assessment 
B) Pain level during activity 
C) Completion of short-term goals 
D) Ability to take a shower

Question 5

How many general topics should the objective section contain when used in a progress note?

Accepted Answer

A) 4 
B) 5 
C) 6 
D) 7

Question 6

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

Accepted Answer

A) Vital signs, measurements, plan of treatment 
B) Blood pressure, ROM, recommendation for change in plan of care 
C) Oxygen saturation level, wound size, position of the patient 
D) Referral to another discipline, strength measurements, stride length

Question 7

Identify the statement that is NOT an appropriate objective response.

Accepted Answer

A) The patient performed 10 reps, 3 sets of (
B)  elbow flexion. 
B) The patient ambulated (I), 20 ft using FWW, SBA 1x. 
C) The patient performed (I), AROM in shoulder ext., prone, 10x, 1 set. 
D) The patient transferred (I), from EOB to w/c using stand-pivot transfer x2.

Question 8

General objective data provide specific information to the reader and help paint a picture of the treatment session.Identify the data that would be incorrect for the PTA to use in the objective section.

Accepted Answer

A) A description of the intervention provided 
B) A summary of the subjective section 
C) A record of the number of treatment sessions provided 
D) The results of tests and measurements

Question 9

Identify the correct test/measurement that would be included in the objective section of the SOAP note.

Accepted Answer

A) Goals or outcomes review 
B) Rating of pain 
C) Referral to OT services 
D) Girth or circumference measurements

Question 10

In SOAP note documentation, what description is the PT's documentation goal in the objective section?

Accepted Answer

A) Patient's level of pain 
B) Patient's function 
C) Treatment protocol 
D) Treatment plan

Question 11

In proper documentation, it is important for the PTA to demonstrate that skilled intervention is necessary and that the activity cannot be performed by anyone other than a professional.Identify the statement that fits this parameter.

Accepted Answer

A) The patient performed an (I) transfer from BS to w/c with SBA x2 with appropriate VC regarding proper body mechanics. 
B) The patient reported that he was able to get out of bed today without any help. 
C) The patient needs to return to the physician for another update and script for continued services. 
D) The patient performed quad sets 10x, 3 sets today compared with 10x, 1 set last session.

Question 12

Why is it important to describe the patient's level of function in the objective section of the SOAP note?

Accepted Answer

A) It helps determine how much pain the patient is experiencing. 
B) It will help determine what services the patient needs. 
C) This information is not necessary in this section of the SOAP note. 
D) It will help the therapist determine whether the level of function improves.

Question 13

Why is it important to provide sufficient information when writing objective information?

Accepted Answer

A) The treating therapist can remember what he or she did during the last session. 
B) Another therapist can reproduce the treatment session if the first therapist is absent. 
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 14

Who is responsible for changing the goals that fall outside the plan of care during the treatment session?

Accepted Answer

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

Question 15

Why is it important to provide documentation related to the patient's increase in strength?

Accepted Answer

A) It provides a means of showing treatment effectiveness. 
B) It helps the patient decide whether therapy is helping. 
C) It provides the family with a measurement of how they think the patient is progressing. 
D) It helps the physician determine how many more treatment sessions are necessary.

Question 16

Why is documenting the patient's record of attendance important in the treatment program?

Accepted Answer

A) It ensures that the patient will continue to attend therapy sessions. 
B) It forces the patient to arrive on time for all of the treatment sessions. 
C) It reflects the patient's compliance with the treatment program. 
D) It makes the patient feel guilty when a treatment session is missed.

Question 17

In the objective section of the SOAP note, what is required to meet the criteria for information given in this section?

Accepted Answer

A) The therapist needs to paint a picture of the treatment session in order to reproduce what occurred. 
B) The therapist must be able to determine what the patient's outcomes will be for the plan of care. 
C) The therapist must be able to provide the past medical history to determine the plan of action. 
D) The therapist must describe a plan of care that includes the patient's ability to function in the gym.

Question 18

What information should be included in the objective 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

Question 19

Identify the correct objective statement.

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 demonstrated the HEP using McKenzie exercises patterns. 
D) Patient walks with a shuffling gait pattern with (R) hip, knee, and ankle in flexion.

Question 20

Which individual is responsible for determining when the patient should be discharged from therapy services?

Accepted Answer

A) Physician 
B) PT 
C) PTA 
D) MSW

Exam 11: What Is Objective Data and Why Is It Important