NURS 5220 SOAP NOTE ASSIGNMENT 1 QUESTIONS
COMPLETE WITH CORRECT ANSWERS & RATIONALES
1. A patient presents with a chief complaint of "chest pain." Which of the
following is the MOST critical element to document in the "History of Presenting
Illness" (HPI) for this symptom?
A. The patient's family history of heart disease.
B. The patient's current list of medications.
C. The quality and character of the pain (e.g., sharp, crushing, burning).
D. The patient's social history, including smoking status.
Answer: C. The quality and character of the pain (e.g., sharp, crushing, burning).
Explanation: The HPI is a detailed, chronological description of the patient's
current problem. The "OLDCARTS" (Onset, Location, Duration, Character,
Aggravating/Alleviating factors, Radiation, Temporal pattern, Severity) mnemonic
is essential for a thorough HPI. Character (e.g., crushing vs. sharp) is a key
differentiator in chest pain (e.g., cardiac vs. musculoskeletal vs. gastrointestinal).
Family history, medications, and social history are vital but are documented in
other sections of the SOAP note, not the HPI.
2. In a SOAP note, under which section would you document the patient's
statement, "I feel a sharp pain in my right knee when I climb stairs"?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: A. Subjective
Explanation: The Subjective section contains information reported by the patient,
including their chief complaint, history of presenting illness, review of systems,
,and personal/social/family history. It is the patient's narrative of their experience,
which cannot be directly measured by the clinician.
3. Which part of the SOAP note contains measurable, quantifiable data obtained
by the healthcare provider?
A. Plan
B. Assessment
C. Subjective
D. Objective
Answer: D. Objective
Explanation: The Objective section is for factual, observable data gathered during
the examination. This includes vital signs, physical exam findings (inspection,
palpation, percussion, auscultation), laboratory results, and imaging studies. It is
the "measurable" part of the note.
4. When documenting a patient's blood pressure of 142/90 mmHg, this finding
belongs in which section of the SOAP note?
A. Assessment
B. Subjective
C. Objective
D. Plan
Answer: C. Objective
Explanation: Vital signs are objectively measured data. They are not subjective
(patient-reported) and are a part of the physical exam findings. The assessment is
the synthesis of subjective and objective data, and the plan is the proposed
treatment.
5. What is the primary purpose of the "Assessment" section in a SOAP note?
A. To list the patient's medications and dosages.
B. To document the patient's vital signs and physical exam findings.
,C. To synthesize the subjective and objective data to form a clinical diagnosis or
differential diagnosis.
D. To create a detailed plan for further testing and treatment.
Answer: C. To synthesize the subjective and objective data to form a clinical
diagnosis or differential diagnosis.
Explanation: The Assessment is the analytical heart of the note. It's where you
interpret the patient's story (Subjective) and the exam/lab findings (Objective) to
arrive at a diagnosis or a list of possible diagnoses (differential). The plan is then
based on the assessment.
6. A patient reports a history of hypertension. This information is BEST
documented in which section?
A. Review of Systems (ROS)
B. Chief Complaint
C. History of Presenting Illness (HPI)
D. Past Medical History (PMH)
Answer: D. Past Medical History (PMH)
Explanation: The Past Medical History includes all of a patient's pre-existing
medical conditions, surgeries, hospitalizations, and major illnesses. Hypertension
is a chronic condition that predates the current visit, so it belongs in the PMH.
7. Which of the following is the MOST appropriate way to document a patient's
chief complaint?
A. "The patient presents with shortness of breath that has been worsening over
the past three days."
B. "Patient reports shortness of breath."
C. "Shortness of breath."
D. "Patient is short of breath due to possible pneumonia."
Answer: C. "Shortness of breath."
Explanation: The Chief Complaint is a concise statement in the patient's own
, words (or a brief, direct quote) describing the primary reason for the visit. It
should be short, one to a few words, and avoid any diagnostic interpretations.
8. A "Review of Systems" (ROS) is documented in which section of the SOAP
note?
A. Objective
B. Assessment
C. Plan
D. Subjective
Answer: D. Subjective
Explanation: The Review of Systems is a systematic review of the patient's body
systems, asking about symptoms not related to the chief complaint. It is patient-
reported information and thus belongs in the Subjective section.
9. When writing a "Plan" in a SOAP note, what is the recommended approach?
A. To only order diagnostic tests.
B. To write a narrative paragraph summarizing the patient's condition.
C. To create a detailed, evidence-based plan that addresses each diagnosis or
problem, often using a "problem-based" format.
D. To list the patient's medications and their side effects.
Answer: C. To create a detailed, evidence-based plan that addresses each
diagnosis or problem, often using a "problem-based" format.
Explanation: The Plan should be organized and specific. A problem-based format
(e.g., Problem #1: Hypertension, Problem #2: Obesity) is best practice. For each
problem, you should include diagnostic tests, medications, patient education,
referrals, and follow-up plans.
10. Which of the following is considered part of the Objective data?
A. The patient's report of nausea.
B. The patient's family history of cancer.
COMPLETE WITH CORRECT ANSWERS & RATIONALES
1. A patient presents with a chief complaint of "chest pain." Which of the
following is the MOST critical element to document in the "History of Presenting
Illness" (HPI) for this symptom?
A. The patient's family history of heart disease.
B. The patient's current list of medications.
C. The quality and character of the pain (e.g., sharp, crushing, burning).
D. The patient's social history, including smoking status.
Answer: C. The quality and character of the pain (e.g., sharp, crushing, burning).
Explanation: The HPI is a detailed, chronological description of the patient's
current problem. The "OLDCARTS" (Onset, Location, Duration, Character,
Aggravating/Alleviating factors, Radiation, Temporal pattern, Severity) mnemonic
is essential for a thorough HPI. Character (e.g., crushing vs. sharp) is a key
differentiator in chest pain (e.g., cardiac vs. musculoskeletal vs. gastrointestinal).
Family history, medications, and social history are vital but are documented in
other sections of the SOAP note, not the HPI.
2. In a SOAP note, under which section would you document the patient's
statement, "I feel a sharp pain in my right knee when I climb stairs"?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer: A. Subjective
Explanation: The Subjective section contains information reported by the patient,
including their chief complaint, history of presenting illness, review of systems,
,and personal/social/family history. It is the patient's narrative of their experience,
which cannot be directly measured by the clinician.
3. Which part of the SOAP note contains measurable, quantifiable data obtained
by the healthcare provider?
A. Plan
B. Assessment
C. Subjective
D. Objective
Answer: D. Objective
Explanation: The Objective section is for factual, observable data gathered during
the examination. This includes vital signs, physical exam findings (inspection,
palpation, percussion, auscultation), laboratory results, and imaging studies. It is
the "measurable" part of the note.
4. When documenting a patient's blood pressure of 142/90 mmHg, this finding
belongs in which section of the SOAP note?
A. Assessment
B. Subjective
C. Objective
D. Plan
Answer: C. Objective
Explanation: Vital signs are objectively measured data. They are not subjective
(patient-reported) and are a part of the physical exam findings. The assessment is
the synthesis of subjective and objective data, and the plan is the proposed
treatment.
5. What is the primary purpose of the "Assessment" section in a SOAP note?
A. To list the patient's medications and dosages.
B. To document the patient's vital signs and physical exam findings.
,C. To synthesize the subjective and objective data to form a clinical diagnosis or
differential diagnosis.
D. To create a detailed plan for further testing and treatment.
Answer: C. To synthesize the subjective and objective data to form a clinical
diagnosis or differential diagnosis.
Explanation: The Assessment is the analytical heart of the note. It's where you
interpret the patient's story (Subjective) and the exam/lab findings (Objective) to
arrive at a diagnosis or a list of possible diagnoses (differential). The plan is then
based on the assessment.
6. A patient reports a history of hypertension. This information is BEST
documented in which section?
A. Review of Systems (ROS)
B. Chief Complaint
C. History of Presenting Illness (HPI)
D. Past Medical History (PMH)
Answer: D. Past Medical History (PMH)
Explanation: The Past Medical History includes all of a patient's pre-existing
medical conditions, surgeries, hospitalizations, and major illnesses. Hypertension
is a chronic condition that predates the current visit, so it belongs in the PMH.
7. Which of the following is the MOST appropriate way to document a patient's
chief complaint?
A. "The patient presents with shortness of breath that has been worsening over
the past three days."
B. "Patient reports shortness of breath."
C. "Shortness of breath."
D. "Patient is short of breath due to possible pneumonia."
Answer: C. "Shortness of breath."
Explanation: The Chief Complaint is a concise statement in the patient's own
, words (or a brief, direct quote) describing the primary reason for the visit. It
should be short, one to a few words, and avoid any diagnostic interpretations.
8. A "Review of Systems" (ROS) is documented in which section of the SOAP
note?
A. Objective
B. Assessment
C. Plan
D. Subjective
Answer: D. Subjective
Explanation: The Review of Systems is a systematic review of the patient's body
systems, asking about symptoms not related to the chief complaint. It is patient-
reported information and thus belongs in the Subjective section.
9. When writing a "Plan" in a SOAP note, what is the recommended approach?
A. To only order diagnostic tests.
B. To write a narrative paragraph summarizing the patient's condition.
C. To create a detailed, evidence-based plan that addresses each diagnosis or
problem, often using a "problem-based" format.
D. To list the patient's medications and their side effects.
Answer: C. To create a detailed, evidence-based plan that addresses each
diagnosis or problem, often using a "problem-based" format.
Explanation: The Plan should be organized and specific. A problem-based format
(e.g., Problem #1: Hypertension, Problem #2: Obesity) is best practice. For each
problem, you should include diagnostic tests, medications, patient education,
referrals, and follow-up plans.
10. Which of the following is considered part of the Objective data?
A. The patient's report of nausea.
B. The patient's family history of cancer.
