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PC716 Physical Assessment Exam 1
Questions and Correct Answers/ Latest
Update / Already Graded
What are all the sections of the Comprehensive Health Visit and it's
documentation?
Ans: Comprehensive Health Visit and its Documentation means
the provider does everything.
S:
CC
HPI
Active Medical History
Past Medication History (childhood/adult illness resolved,
surgical, accidents, women's health, psychiatric, health
maintenance)
Medications
Allergies
Immunizations
Family History (3 generations)
Social History
ROS (complete of every system)
O:
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Physical Exam (a complete head to toe exam appropriate for
patient)
Labs & Diagnostics (available at the time of the visit)
A:
Medical Diagnosis or Diagnoses that can be coded and billed for
P:
Diagnostics (that need to be done but not available at visi t)
Therapeutics (treatments or prescriptions)Patient Education
Follow-up (why do they need to return)Referral
What is the same but different about Comprehensive and Episodic
Health Visits and their documentation?
Ans: Both the comprehensive and episodic/focused visit rely on
the SOAP Framework for the order of the visit and the
documentation. The comprehensive requires the provider to
collect all elements of the history and complete head to toe
physical exam to arrive at an appropriate diagnosis an d plan of
care. Common reasons for a comprehensive visit is establishing
care, preventative visit, employment physical, etc.
The episodic/focused however allows the provider to only
collect data they feel is appropriate to evaluate the concern the
All rights reserved © 2025/ 2026 |
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patient has presented for in turn leading to a hypothesis driven
physical exam based on that history, and then arriving at a
diagnosis (assessment), and a plan of management.
How can you tell subjective and objective apart?
Ans: Subjective data is just that what the patient says. I
imagine myself as the provider with my eyes closed and my
hands in my pockets. The only way I gather data is by what the
patient tells me. This also includes subjective only screening
tools.
Objective data is when the provider observes/inspects,
palpates, percusses, or auscultates. Objective data is also
diagnostic results or clinical/screening tools utilizing objective
data.
What are the three ways the SOAP Framework is used?
Ans: 1. Order the patient visit. First gathering history (S), then
completing an exam (O), then sitting down with the patient to
discuss the diagnosis (A), and then collaborating with the
patient on a plan of management (P).
2. SOAP is how we communicate with those on the healthcare
team via our documentation. There are rules to where we
All rights reserved © 2025/ 2026 |
PC716 Physical Assessment Exam 1
Questions and Correct Answers/ Latest
Update / Already Graded
What are all the sections of the Comprehensive Health Visit and it's
documentation?
Ans: Comprehensive Health Visit and its Documentation means
the provider does everything.
S:
CC
HPI
Active Medical History
Past Medication History (childhood/adult illness resolved,
surgical, accidents, women's health, psychiatric, health
maintenance)
Medications
Allergies
Immunizations
Family History (3 generations)
Social History
ROS (complete of every system)
O:
All rights reserved © 2025/ 2026 |
, Page |2
Physical Exam (a complete head to toe exam appropriate for
patient)
Labs & Diagnostics (available at the time of the visit)
A:
Medical Diagnosis or Diagnoses that can be coded and billed for
P:
Diagnostics (that need to be done but not available at visi t)
Therapeutics (treatments or prescriptions)Patient Education
Follow-up (why do they need to return)Referral
What is the same but different about Comprehensive and Episodic
Health Visits and their documentation?
Ans: Both the comprehensive and episodic/focused visit rely on
the SOAP Framework for the order of the visit and the
documentation. The comprehensive requires the provider to
collect all elements of the history and complete head to toe
physical exam to arrive at an appropriate diagnosis an d plan of
care. Common reasons for a comprehensive visit is establishing
care, preventative visit, employment physical, etc.
The episodic/focused however allows the provider to only
collect data they feel is appropriate to evaluate the concern the
All rights reserved © 2025/ 2026 |
, Page |3
patient has presented for in turn leading to a hypothesis driven
physical exam based on that history, and then arriving at a
diagnosis (assessment), and a plan of management.
How can you tell subjective and objective apart?
Ans: Subjective data is just that what the patient says. I
imagine myself as the provider with my eyes closed and my
hands in my pockets. The only way I gather data is by what the
patient tells me. This also includes subjective only screening
tools.
Objective data is when the provider observes/inspects,
palpates, percusses, or auscultates. Objective data is also
diagnostic results or clinical/screening tools utilizing objective
data.
What are the three ways the SOAP Framework is used?
Ans: 1. Order the patient visit. First gathering history (S), then
completing an exam (O), then sitting down with the patient to
discuss the diagnosis (A), and then collaborating with the
patient on a plan of management (P).
2. SOAP is how we communicate with those on the healthcare
team via our documentation. There are rules to where we
All rights reserved © 2025/ 2026 |
