Medical Terminology and Abbreviations

Question 1

4 Types of Patient Notes

Answer 1

1) Initial Eval
2) Daily Treatment Note
3) Progress Note
4) Discharge Note

Question 2

Five components of a patient note

Answer 2

1) Examination
2) evaluation
3) diagnosis
4) prognosis
5) plan of care

Question 3

Who introduced the SOAP note?

Answer 3

Dr. Lawrence Weed

Question 4

Four parts to a SOAP note

Answer 4

S = Subjective
O = Objective
A = Assessment
P = Plan

Question 5

What is the initial section of SOAP a note called and what is written there?

Answer 5

Problem section

-information gathered from the medical record is written here

Question 6

What is included in the examination process?

Answer 6

• Gathering information from the chart other caregivers the patient and the family.
• Systems review.
• Tests and measures

Question 7

Where can the examination information be found in a SOAP note?

Answer 7

In the subjective and objective sections

Question 8

What is written in the subjective section of a SOAP note?

Answer 8

All information gathered from the patient

Question 9

What are the 9 Headings can be found in the subjective section of a soap note

Answer 9

(1) Current conditions/chief complaint
(2) prior level of function
(3) patient goals
(4) social history
(5) employment status
(6) living environment
(7) general health status
(8) medical/surgical history
(9) medications

Question 10

What is written in the objective section of a SOAP note?

Answer 10

Information gathered by the therapist from performing systems review and tests and measures

Question 11

8 system reviews

Answer 11

1) Cardiovascular/pulmonary
2) integumentary system
3) musculoskeletal
4) neuromuscular
5) communication style/abilities
6) affect
7) cognition
8) learning barriers

Question 12

What can be found in the diagnosis portion of the Assessment section of a SOAP Note?

Answer 12

A discussion of the relationship of the patient’s impairments

Question 13

What can be found in the prognosis portion of the Assessment section of a SOAP Note?

Answer 13

The predicted level of improvement that the patient will be able to achieve and the predicted amount of time to achieve it

• Rehab potential
• Plans for discharge
• Future therapy plans
• Projected final outcomes

Question 14

What can be found in the plan of care portion of the Assessment section of a SOAP Note?

Answer 14

• Expected outcomes (long-term goals)
• Anticipated outcomes (short-term goals)
• Interventions and home exercise program

Question 15

What are the seven parts to a patient/client management note?

Answer 15

• History
• Systems review
• Tests and measures
• Evaluation
• Diagnosis
• Prognosis
• Plan of care

Question 16

What can be found in the history section of a patient/client management note?

Answer 16

The information gathered about the patient’s history

Question 17

What can be found in the systems review section of a patient/client management note?

Answer 17

Information gathered from performing a brief screening of the patient’s major systems such as blood pressure, height, weight, etc.

Question 18

What can be found in the tests and measures section of a patient/client management note?

Answer 18

Results from specific tests and measures performed by the physical therapist

Question 19

When can a hyphen used?

Answer 19

Only instead of the word to or through

Example: AROM: 0-68

Question 20

When can a semicolon be used?

Answer 20

To contact related sentences

Question 21

When can a colon be used?

Answer 21

Instead of the word “is”

Question 22

What is found in the assessment portion of a SOAP note?

Answer 22

Diagnosis
Prognosis
Plan of care