SOAP Notes

Question 1

The SOAP Note was introduced by

Answer 1

Dr. Lawrence Weed

Question 2

Includes gathering information from the chart, other caregivers, the patient, the
patient’s family, caretakers, and friends

Answer 2

Examination

Question 3

Includes a
systems review and tests and measures performed by the
therapist

Answer 3

Examination

Question 4

Information gathered
in the examination is presented according to the nature
of the

Answer 4

Sources of Information

Question 5

The information gathered
from the medical record is usually written into an initial
section of the note labeled the

Answer 5

Problem

Question 6

The information
gathered from the patient and his or her family, caretakers, and friends is usually written into a section labeled
the

Answer 6

Subjective section

Question 7

Information gathered by the
therapist performing a systems review and tests and
measures is usually written into a section labeled the

Answer 7

Objective section

Question 8

Includes a synthesis and discussion of the clinical findings, usually presented in
the form of a problem list and/or discussion of factors
influencing the patient’s condition or progress in therapy

Answer 8

Evaluation

Question 9

Includes a discussion
of the relationship of the patient’s functional deficits
to the patient’s impairment

Answer 9

Diagnosis

Question 10

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

Answer 10

Prognosis

Question 11

Includes the Expected Outcomes
(Long-Term Goals), Anticipated Goals (Short-Term
Goals), and Interventions, including an Education Plan
for the patient or the patient’s caregivers or significant
other

Answer 11

Plan of Care