SOAP

Question 1

Refers to whether
symptoms have a set pattern, such as occurring every
evening.

Answer 1

TEMPORAL PATTERNS

Question 2

The diagnosis or condition
the patient has.

Answer 2

ASSESSMENT

Question 3

Determine if there are other symptoms.

Answer 3

SYMPTOMS-ASSOCIATED

Question 4

Involves factors you can measure, see, hear, feel or
smell.

Answer 4

OBJECTIVE

Question 5

This refers to how you are going to address the
patient’s problem.

Answer 5

PLAN

Question 6

This refers to subjective observations
that are verbally expressed by the patient,
such as information about symptoms.

Answer 6

SUBJECTIVE

Question 7

A method of
documentation employed by health care
providers to write out notes in a patient’s
chart.

Answer 7

SOAP PROGRESS NOTE

Question 8

An organized summary of all known patient
information.

Answer 8

PATIENT CASE PRESENTATION

Question 9

Reason why a patient seeks medical attention.

Answer 9

CHIEF COMPLAINT

Question 10

Information about the patient’s occupation, marital
status, sexual history and living conditions

Answer 10

SOCIAL HISTORY

Question 11

o Menarche
o Menopause
o History of sexual contact
o Contraception
o Pregnancy

Answer 11

OB-GYNE HISTORY

Question 12

Summarizes all current patient complaints not included in HPI

Answer 12

REVIEW OF SYSTEMS

Question 13

Inspection, palpation, percussion and
auscultation

Answer 13

PHYSICAL EXAMINATION

Question 14

Includes brief description of patient problems
unrelated to the present illness

Answer 14

PAST MEDICAL HISTORY

Question 15

Consist a brief summary of the medical histories of
the patient’s first degree relatives

Answer 15

FAMILY HISTORY

Question 16

Obtaining this is the 1
st step of medicine
reconciliation process

Answer 16

MEDICATION HISTORY

Question 17

Primary diagnosis

Answer 17

ADMITTING DIAGNOSIS

Question 18

Brief enumeration of the patient’s problems, starting
with the most acute problem.

Answer 18

PATIENT PROBLEM LIST AND INITIAL PLANS

Question 19

Presented after the physical assessment
section of the patient case

Answer 19

LABORATORY AND DIAGNOSTIC TEST RESULTS

Question 20

Consists of a list of all medicines taken by the
patient prior to admission.

Answer 20

MEDICATION HISTORY

Question 21

Presented and documented in the patient’s own
words.

Answer 21

HISTORY OF PRESENT ILLNESS

Question 22

Refers to what area of the body hurts.

Answer 22

LOCATION

Question 23

Refers to the type of pain, such as stabbing, dull or aching.

Answer 23

CHARACTER

Question 24

Determine if anything reduces or
eliminates symptoms and if anything makes them worse.

Answer 24

ALLEVIATING FACTORS

Question 25

Determine from the patient when the symptoms first started

Answer 25

ONSET

Question 26

Purpose of a SOAP note

Answer 26

Standard format for organizing
patient information.

Question 27

It provides a thorough and detailed picture of the
patient at the time of the presentation or initial
patient interaction

Answer 27

PATIENT CASE PRESENTATION

Question 28

Contains information about the patients’ use of
tobacco, alcohol and illicit drugs.

Answer 28

SOCIAL HISTORY

Question 29

Findings are presented.

Answer 29

PERTINENT POSITIVE

Question 30

Date and time of admission
Patients name
Gender
Race
Address
Marital Status

Answer 30

GENERAL PATIENT INFORMATION