Final Exam

Question 1

A physical therapist will have to make SOAP Notes. What does SOAP stand for?

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

Information gathered from the patient, family, caretakers, or friends and includes the review of systems is written in the (subjective/objective) section

Answer 2

subjective

Question 3

Information gathered through tests PT completes during examination is listed in the (subjective/objective) section

Answer 3

objective

Question 4

The evaluation, diagnosis, and prognosis are found in the _____ section of SOAP notes

Answer 4

assessment

Question 5

In regards to the subjective section of SOAP notes, what is important to identify the source of information

Answer 5

“patient states. . .”

“patient’s wife state. . .”

Question 6

The ____ section of SOAP notes is where the results of tests and measures performed and the therapists observations are recorded

Answer 6

objective

Question 7

(subjective/objective) data are the measurable or observable pieces of information used to formulate the plan of care

Answer 7

objective

Question 8

In regards to the objective section of SOAP notes, what is important to identify sources of information

Answer 8

When discussing tests and measurements performed or generalized problems affecting multiple parts of the body like ambulation, transfers, ROM, strength, sensation, and balance

Question 9

What three categories are found under the assessment section of SOAP notes

Answer 9

evaluation, diagnosis, prognosis

Question 10

Which section of SOAP notes involves the structure of expected outcomes and anticipated goals by using the acronym ABCD

Answer 10

plan of care

Question 11

In regards to the plan of care section of SOAP notes what is important to identify sources of information

Answer 11

“WILL ambulate modified independently. . . “

Question 12

Is this an example of subjective, objective, assessment, or plan of care notes?

Pt reports 1/10 pain after treatment this date, primarily over left rhomboid muscle belly

Answer 12

subjective

Question 13

Is this an example of subjective, objective, assessment, or plan of care notes?

Unilateral supraspinatus lifts, bilateral UE, 0#, 1 x 12 reps

Answer 13

objective

Question 14

Is this an example of subjective, objective, assessment, or plan of care notes?

In hooklying: manual certival spine traction/distraction in ~20 degrees flexion angle with 60 sec holds and 20 sec rest x10 reps

Answer 14

objective

Question 15

Is this an example of subjective, objective, assessment, or plan of care notes?

Currently reports 3-4/10 pain in left mid-upper back at present at rest. Patient did work a shift at work this morning, coming to clinic immediately following work

Answer 15

subjective

Question 16

Is this an example of subjective, objective, assessment, or plan of care notes?

Will demonstrate normalized cervical spine alignment in sitting and standing within 6 wks to facilitate normalized ostekinematics

Answer 16

plan

Question 17

Is this an example of subjective, objective, assessment, or plan of care notes?

PT demonstrated and then practiced with patient correct positioning for sleeping at night on back as well as in sidelying with use of small towel roll to promote improved spinal alignment to decrease pain and neuro signs and symptoms into left UE

Answer 17

objective

Question 18

Is this an example of subjective, objective, assessment, or plan of care notes?

In prone over 1 pillow at pelvis: myofascial release, cross friction massage, and trigger point releases in left upper trapezius, levator scapulae, rhomboids

Answer 18

objective

Question 19

Is this an example of subjective, objective, assessment, or plan of care notes?

Patient tolerates treatment good with decreased reported pain level and improved spinal alignment after session this date. Good effort demonstrated during treatment with no additional encouragement required for full effort. Does require intermittent redirection to task secondary to patient continuing to be easily distracted by self-initiated conversation.

Answer 19

assessment

Question 20

Is this an example of subjective, objective, assessment, or plan of care notes?

Alignment before intervention: in standing: minimal right lateral shift of C4-6 on C6-7, minimal left lateral shift of T2 and T3

Answer 20

objective

Question 21

Is this an example of subjective, objective, assessment, or plan of care notes?

States “I don’t have the tingling in my left arm anymore, but I still have the pulling, heavy arm feeling.”

Answer 21

subjective

Question 22

Is this an example of subjective, objective, assessment, or plan of care notes?

Education: Postural re-education/reinforcement as previous, review of correct HEP that patient should be completing

Answer 22

objective

Question 23

Is this an example of subjective, objective, assessment, or plan of care notes?

Will increase left cervical spine rotation AROM by 40 degrees to facilitate more normalized head movement for completion of functional tasks, such as driving, within 6 weeks

Answer 23

plan

Question 24

Is this an example of subjective, objective, assessment, or plan of care notes?

Patient continues to progress in slow but steady manner toward goals as currently written. All goals remain appropriate to continue with at this time as written.

Answer 24

assessment

Question 25

Is this an example of subjective, objective, assessment, or plan of care notes?

Incorporate body mechanics training for work station next treatment, time permitting.

Answer 25

plan

Question 26

Is this an example of subjective, objective, assessment, or plan of care notes?

Will continue to be seen 1x/wk secondary to pt’s work schedule for up to 6 total visits per insurance

Answer 26

plan

Question 27

Is this an example of subjective, objective, assessment, or plan of care notes?

In 6 wks, will be indep with lifting boxes of fruit from the ground using correct body mechanics

Answer 27

plan

Question 28

What section of the assessment involves impairments, restrictions, personal factors, and environmental factors

Answer 28

evaluation

Question 29

Is this an example of an evaluation, diagnosis or prognosis?

The patient has shortened muscles on the front of her hips and an increased curve in the lower part of her back causing back pain when the patient stands.

Answer 29

diagnosis

Question 30

Is this an example of an evaluation, diagnosis or prognosis?

The patient’s right shoulder muscle weakness and resulting abnormal motion at the joint are causing inflammation in her shoulder joint causing pain when reaching with her right arm.

Answer 30

diagnosis

Question 31

Is this an example of an evaluation, diagnosis or prognosis?

Pt has excellent potential to meet expected outcomes of therapy due to his excellent motivation to return to work, young age, no prior injury to the right shoulder, and overall good physical conditioning prior to injury. Expected to progress being able to successfully and safely complete light duty tasks for work in 3 wks and return to full duty in 6 wks

Answer 31

prognosis

Question 32

Is this an example of an evaluation, diagnosis or prognosis?

Pt should continue to make positive progression toward goals permitting pt to return to home with assistance, as pt has demonstrated good functional recovery since onset of symptoms, is motivated, and has supportive family. However, pt’s uncontrolled HTN, that is still being regulated, and long-standing type 1 DM may negatively impact pt’s progress

Answer 32

prognosis

Question 33

Is this an example of an evaluation, diagnosis or prognosis?

Pt’s decreased left leg strength, sensation, and tone changes; neglecting left side of body, decreased vision, and attention to tasks due to his medical dx are causing him to be unable to walk and complete his volunteer and community work

Answer 33

diagnosis

Question 34

Is this an example of an evaluation, diagnosis or prognosis?

Impairments: overall decreased strength of all left LE musculature, decreased AROM left knee and hip throughout, decrease in muscle endurance and exercise tolerance. NWB left LE status. Activity & Participation Restrictions: needs mod assist of 1 person to amb with a walker on level surfaces less than 25 feet & for transfers sit to/from stand, supine to/from sit, & on/off toilet. Personal Factors: sedentary for 30 yrs in both job & home life. Environmental: single 8” step to enter home without rail; nearest family member is 1,000 miles away.

Answer 34

evaluation

Question 35

Is this an example of an evaluation, diagnosis or prognosis?

Pt is NWB left LE due to left femur fx s/p ORIF on 03/24/2021 & has decreased movement & muscle strength & endurance in the left hip & knee due to injury causing difficulty with transferring & walking resulting in need for assist to complete these tasks

Answer 35

diagnosis

Question 36

Is this an example of an evaluation, diagnosis or prognosis?

Demonstrates good rehab potential for diagnosis secondary to good response to recent surgery as neuro signs and symptoms have resolved since surgery to pre-surgery level

Answer 36

prognosis

Question 37

Is this an example of an evaluation, diagnosis or prognosis?

Patient is very motivated to improve current condition, & was in good physical condition & active prior to onset of signs and symptoms 6 month prior to surgery

Answer 37

prognosis