SOAP

Question 1

information you have learned from the patient

Answer 1

subjective

Question 2

it describes patient’s condition in narrative form

Answer 2

subjective

Question 3

subjective data consists 2 parts

Answer 3

chief complaint and hpi

Question 4

brief statement of the patient quoted as the purpose of the visit

Answer 4

chief complaint

Question 5

patient’s condition in narrative form

Answer 5

history of present illness

Question 6

hpi includes

Answer 6

onset, chronology, quality, severity, modifying factors, additional symptoms, treatment

Question 7

documents repeatable and traceable facts about the patient’s status

Answer 7

objective data

Question 8

objective data includes: (4)

Answer 8

1. vital signs (pulse rate, temperature, blood pressure, respiratory rat)
2. lab results
3. findings from physical examination (posture, bruising, abnormalities)
4. age and weight

Question 9

occurs during the maximal contraction of the heart

Answer 9

systolic pressure

Question 11

resting pressure

Answer 11

diastolic pressure

Question 12

normal bp

Answer 12

120/80

Question 13

physical expansion of the artery

Answer 13

pulse rate

Question 14

normal pulse rate of newborn, toddler, older child, adolescent, adult

Answer 14

1. newborn - 130-150
2. toddler - 100-120
3. older child - 60-100
4. adolescents - 80-100
5. adults - 50-80

Question 15

normal range of respiratory rate

Answer 15

16-20 breaths per minute

Question 16

main reason for checking body temperature

Answer 16

solicit any signs of infection and inflammation in the presence of fever

Question 17

normal body temperature

Answer 17

not more than 38.5 c

Question 18

Physician’s medical diagnoses for the medical 
visit on the given date of a note written.

Answer 18

assessment

Question 19

This describes what the health care provider will do to treat the patient

Answer 19

plan

Question 20

treatment plan should be dividede into (4)

Answer 20

1. diagnostics
2. therapeutic
3. patient education
4. health promotion strategies

Question 21

purpose of documentation

Answer 21

1. legal document
2. method of communication
3. reimbursement of third party payers
4. discharge decisions

Question 22

guidelines in writing soap

Answer 22

accuracy, brevity, clarity, correcting errors