Quiz
Clinical SOAP Note
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Perguntas do quiz (39)
1Is the clinical SOAP note a widely used format to organize information?
- AYes; this is how health care professionals communicate
- BNo
2How does one address a mistake in a clinical soap note?
- Adraw a line through it, write error, initials, and date it
- Bdraw a line through it, write initials, and date it
3How does one document in the clinical soap note?
- Ausing pen and no white out
- Busing pencil and no white out
4The "S components" are the patient's [blank_start]story[blank_end]. Be concise, but tell story. Includes: [blank_start]chief complaint[blank_end] (cc) with [blank_start]duration[blank_end], [blank_start]history of present illness[blank_end] (HPI)--use the [blank_start]7 factors[blank_end], any information pertinent to the "[blank_start]cc[blank_end]," [blank_start]past[blank_end] medical history--secondary diagnoses, [blank_start]personal[blank_end] and [blank_start]social[blank_end] history, [blank_start]family[blank_end] history, and [blank_start]review of systems[blank_end] (ROS)--ask patient about every body system, helps determine [blank_start]associated manifestations[blank_end].
- Astory
- Bchief complaint
- Cduration
- Dhistory of present illness
- E7 factors
- Fcc
- Gpast
- Hpersonal
- Isocial
- Jfamily
- Kreview of systems
- Lassociated manifestations
5The 7 factors include: [blank_start]setting[blank_end], [blank_start]chronology[blank_end], [blank_start]location[blank_end], [blank_start]quality[blank_end], [blank_start]quantity[blank_end], [blank_start]aggravating/alleviating factors[blank_end], and [blank_start]associated manifestations[blank_end].
- Asetting
- Bchronology
- Clocation
- Dquality
- Equantity
- Faggravating/alleviating factors
- Gassociated manifestations
6Example of what?
This is a 22 year old female with no history of present illness who presents to the clinic today c/o ____ for ____ (duration).- AS components
- BO components
- CA components
- DP components
7Which of the 7 factors asks:
(1) where was patient at onset of symptoms?
(2) what were they doing at onset symptoms?- Asetting
- Bchronology
- Clocation
8Which of the 7 factors tells the patients story from start to finish? Use notes to develop the timeline since patient will tell story out of order.
- Asetting
- Bchronology
- Clocation
9Which of the 7 factors describes the location of a symptom on the body? (i.e. what side? both? lower/upper?)
- Asetting
- Bchronology
- Clocation
10Which of the 7 factors is a description of the symptom? (i.e. achy, throbbing, stabbing)
- Aquality
- Bquantity
- Clocation
11Which of the 7 factors describes the severity of symptoms using mild, moderate, or severe, the pain scale (0-10), and if something can measure...estimate.
- Aquantity
- Bquality
- Cchronology
12This is an example of which of the 7 factors?
On a scale of 0-10, 0 being no pain and 10 being the most pain, pt rates pain as 8/10.- Aquantity
- Bquality
- Cchronology
13Which of the 7 factors describes what makes it worse/better?
- Aaggravating/alleviating factors
- Bquality
- Cassociated manifestations
14Which of the 7 factors describes positive symptoms: what else is the patient complaining of and pertinent negatives: potential symptoms that are associated with the "cc" but the patient denies having.
- Aassociated manifestations
- Baggravating/alleviating factors
- Cquality
15What should one write if the patient has no pertinent negatives under associated manifestations? if patient has pertinent negatives?
- Awrite no pertinent negatives (patient denies any pertinent negative manifestations); always note negatives
- Bleave blank; always note negatives
16Is the subjective component written in paragraph form?
- Ayes
- Bno
17T/F
The subjective components contain all the information from the seven factors in one paragraph and paragraph two contains any relevant history.- Atrue
- Bfalse
18Intro Statement in Subjective: This is a [blank_start]age[blank_end], [blank_start]race[blank_end] ,[blank_start]gender[blank_end] with no sig/sig [blank_start]past medical history[blank_end] of....[blank_start]complaining of[blank_end] "cc" for [blank_start]x time[blank_end], then [blank_start]7 factors[blank_end] and [blank_start]history[blank_end].
- Aage
- Brace
- Cgender
- Dpast medical history
- Ecomplaining of
- Fx time
- G7 factors
- Hhistory
19What is this an example of?
This is a 4 y/o white female with PMHx of AOM, right year 3 mos ago currently c/o right ear pain x 2 days. Two days ago...
Patient is exposed to second-hand smoke on a daily basis in her home due to her mother's 2 ppd smoking history...- AIntro Statement for Subjective
- BGeneral Statement for Objective
20Which part of the SOAP note are allergies included in?
- AS
- BO
- CA
- DP
21Allergies can be [blank_start]drug/latex[blank_end], [blank_start]food[blank_end], or [blank_start]environment[blank_end] with reaction or [blank_start]NKDA[blank_end] (no known drug allergies). Some people may have [blank_start]seasonal[blank_end] allergies. Always ask what [blank_start]happens[blank_end].
- Adrug/latex
- Bfood
- Cenvironment
- DNKDA
- Eseasonal
- Fhappens
22What part of the soap note are medications included in?
- AS
- BO
- CA
- DP
23Under medications, use the [blank_start]standard format[blank_end]. Include: [blank_start]name[blank_end], [blank_start]strength[blank_end], [blank_start]dose[blank_end], [blank_start]route[blank_end], [blank_start]frequency[blank_end], and [blank_start]+/- reason for taking[blank_end].
- Astandard format
- Bname
- Cstrength
- Ddose
- Eroute
- Ffrequency
- G+/- reason for taking
24After listing medications, write [blank_start]LNMP[blank_end] in women of child bearing age.
- ALNMP
25prn means [blank_start]as needed[blank_end]. If a patient is taking a medication as needed, you must include [blank_start]for what[blank_end].
- Aas needed
- Bfor what
26The "O Components" include: [blank_start]vital signs[blank_end], [blank_start]general statement[blank_end], [blank_start]problem oriented[blank_end] physical exam, and [blank_start]diagnostic studies[blank_end].
- Avital signs
- Bgeneral statement
- Cproblem oriented
- Ddiagnostic studies
27Vital signs include: [blank_start]temperature[blank_end], [blank_start]pulse[blank_end], [blank_start]blood pressure[blank_end], [blank_start]oxygen saturation[blank_end] (RA or oxygen on x amt of liters),and [blank_start]bmi[blank_end].
- Atemperature
- Bpulse
- Cblood pressure
- Doxygen saturation
- Ebmi
28The general statement always includes: [blank_start]age[blank_end], [blank_start]race[blank_end], [blank_start]gender[blank_end], [blank_start]body build[blank_end], [blank_start]distress level[blank_end] and/or [blank_start]behavior/cooperative[blank_end].
- Aage
- Brace
- Cgender
- Dbody build
- Edistress level
- Fbehavior/cooperative
29This is an example of what?
This is a 42 y/o WD/WN BM in NAD.
This is a 52 y/o Hispanic female mildly obese in mild respiratory distress.- Aintro statement in subjective
- Bgeneral statement in objective
30The diagnostic studies included in the O components are studies listed that you have [blank_start]results for[blank_end]. Always put [blank_start]date[blank_end], [blank_start]test[blank_end], and [blank_start]result[blank_end].
- Aresults for
- Bdate
- Ctest
- Dresult
31The A components include: [blank_start]primary diagnosis[blank_end] and [blank_start]secondary diagnosis[blank_end].
- Aprimary diagnosis
- Bsecondary diagnosis
32The primary diagnosis is based on [blank_start]current s/s[blank_end] (chief complaint). There may be [blank_start]more than one[blank_end] primary diagnosis. May need to include [blank_start]R/O[blank_end] and always have a [blank_start]differential diagnosis[blank_end].
- Acurrent s/s
- Bmore than one
- CR/O
- Ddifferential diagnosis
33The secondary diagnosis in the A components include [blank_start]known past medical diagnoses[blank_end]. If there are no secondary diagnoses, write [blank_start]none[blank_end].
- Aknown past medical diagnoses
- Bnone
34The "P components" of the SOAP note include: any further [blank_start]diagnostic studies[blank_end], [blank_start]treatment considerations[blank_end], [blank_start]patient education issues[blank_end], and [blank_start]follow up[blank_end].
- Adiagnostic studies
- Btreatment considerations
- Cpatient education issues
- Dfollow up
35Any further diagnostic studies included in the P components must list each test on a [blank_start]separate line[blank_end]. Specialized tests need a [blank_start]reason[blank_end] why you are ordering them. This way the radiologist knows what to [blank_start]look for[blank_end] and [blank_start]comment on[blank_end].
- Aseparate line
- Breason
- Clook for
- Dcomment on
36Treatment considerations in the P components include any [blank_start]medications[blank_end], heat/cold for [blank_start]how long[blank_end], [blank_start]rest[blank_end]. If writing medications, write out [blank_start]name[blank_end] of prescription on soap note.
- Amedications
- Bhow long
- Crest
- Dname
37The patient education issues in the P components include: [blank_start]side effects[blank_end] of medications prescribed and [blank_start]s/s[blank_end] that should make the patient return to [blank_start]clinic[blank_end] or go to [blank_start]ED[blank_end]. Make sure to document "[blank_start]patient instructed that side effects of[blank_end] ___ [blank_start]are[blank_end]: ____, ____, _____.
- Aside effects
- Bs/s
- Cclinic
- DED
- Epatient instructed that side effects of
- Fare
38The follow up of the P components include: when should the patient return to [blank_start]clinic[blank_end] (RTC) or [blank_start]RTO[blank_end]? If the diagnosis is [blank_start]chronic[blank_end], make sure they come back to office/clinic.
- Aclinic
- BRTO
- Cchronic
39The last thing to put in the soap note is: [blank_start]patient understood[blank_end] and [blank_start]all questions were answered[blank_end]. This is for [blank_start]legal[blank_end] reasons that the patient left with understanding. Also [blank_start]sign[blank_end] the SOAP note.
- Apatient understood
- Ball questions were answered
- Clegal
- Dsign
Informações
- Descrição
- College Intro to Medicine I Quiz sobre Clinical SOAP Note, criado por hce102 em 10-10-2015.
- Autor
- hce102
- Idioma
- English
- Visualizações
- 44
- Etiquetas
- Avaliação
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