Chapter 9 Recording and Reporting

Question 1

What is a “SOAP” note

Answer 1

S - Subjective
O - Objective
A - Assessment
P - Plan of care

Question 2

“S”ubjective

Answer 2

The patient’s own description of their symptoms, feelings, and experiences.

Question 3

“O”bjective

Answer 3

Records factual and measurable information from clinical assessments, tests, and observations.

Question 4

“A”ssessment

Answer 4

Healthcare providers summarize their professional judgment and interpretation of the subjective and objective data.

Question 5

“P”lan

Answer 5

The plan section outlines the healthcare provider’s proposed course of action for the patient.

Question 6

What is “SBAR” format

Answer 6

S - Situation
B - Background
A - Assessment
R - Recommendation

Question 7

“S”ituation

Answer 7

What is the situation you are calling about? Identify yourself, the unit, the patient, and room number.

Question 8

“B”ackground

Answer 8

Pertinent background information. Most recent vital signs and any lab results.

Question 9

“A”ssessment

Answer 9

What is “YOUR” assessment of the situation

Question 10

“R”ecommendations

Answer 10

What is your recommendation about what should happen

Question 11

Name some different types of charting

Answer 11

1) Narrative
2) SOAP
3) Focus
4) PIE
5) Charting by exception
6) Electronic Computerized Charting

Question 12

What is HIPAA?

Answer 12

Health Insurance Portability and Accountability Act

legislation regarding client healthcare confidentiality