Analysis of subjective and objective findings
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NU-650-13-22PCSP Adv Hlth Assessment/Nursing
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Match the term with the intended component of the standard note
Analysis of subjective and objective findings
Patient’s reported symptoms Answer 2
Guidelines for continued care Answer 3
Physical Assessment Finding Answer 4
Question 2
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Which of the following statements most accurately represents the subjective history?
Select one:
a.
Patient’s pain is acute and somatic.
b.
Patient rates the pain 8/10 and describes it as aching.
c.
Patient reports pain relieved with prn use of ibuprofen.
d.
Patient’s reported pain most likely attributed to recent fall.
Question 3
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Family History – Middle daughter, parents separated, but both still living.
Select one:
True
False
Question 4
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Social History – Smoked one pack of cigarettes/day from age 20 to age 35 (15 pack years).
Select one:
True
False
Question 5
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Past Medical History – Diagnosed with diabetes at age 52. Average home blood glucose monitoring is 125. Last HgbA1C was 7.1 (September 2021). Compliant with Metformin 500mg bid. Last eye exam June, 2021. Last renal function and other labs September 2021 were normal.
Select one:
True
False
Question 6
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Surgical History – Lap cholecystectomy and vaginal hysterectomy.
Select one:
True
False
Question 7
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
ROS – Skin: Denies rashes, lesions, or changes in moles. Skin is warm, dry and intact.
Select one:
True
False
Question 8
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
ROS – GU: Denies problems.
Select one:
True
False
Question 9
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Objective/Physical Exam – Thorax/Lungs: Lungs clear to auscultation bilaterally; expiratory wheeze noted in left lower lobe which patient attributes to recent URI.
Select one:
True
False
Question 10
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Objective/Physical Exam: GI: Abdomen rounded, soft, non-tender to light and deep palpation, tympanic to percussion, BS active in all four quadrants. Liver measured at 8cm. No hepatomegaly, no splenomegaly. Kidneys not palpated. Negative psoas, obturator, and Murphy’s signs. No CVA tenderness.
Select one:
True
False
Question 11
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Assessment – Reported productive cough of yellow sputum, fever of 101.6, and crackles in LLL worrisome for pneumonia.
Select one:
True
False
Question 12
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Identify if the following documentation example is in the SOAP format. You will use True to designate that the example is in SOAP format and False to designate that the example is not in SOAP format.
Example:
Plan – Patient to complete course of penicillin as prescribed.
Select one:
True
False
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