SOLUTIONS 2026 ALREADY PASSED
⫸ What should be included in the Subjective section of a SOAP
note? Answer: Information the patient or caregiver tells you,
including Chief Complaint, History of Present Illness, Past Medical
History, Family History, Social History, and Review of Systems.
⫸ What is the Chief Complaint (CC) in a SOAP note? Answer: A
statement describing the patient's symptoms or problems, using the
patient's own words.
⫸ What is the purpose of the History of Present Illness (HPI) in a
SOAP note? Answer: To provide a chronological description of the
development of the patient's chief complaint, including seven
variables.
⫸ What seven variables should be included in the HPI? Answer:
Location, quality, severity, timing, setting, alleviating and aggravating
factors, and associated signs and symptoms.
⫸ What information is typically documented in the Past Medical
History (PMH)? Answer: Current medications, allergies, prior
illnesses and injuries, operations, hospitalizations, and immunization
status.
, ⫸ What is the significance of Family History (FH) in a SOAP note?
Answer: To update significant medical information about the patient's
family that may relate to the patient's condition.
⫸ What should be included in the Social History (SH) section of a
SOAP note? Answer: Significant activities such as marital status,
living arrangements, occupation, drug, alcohol, or tobacco use,
education, and sexual history.
⫸ What is the Review of Systems (ROS) in a SOAP note? Answer: A
review of 14 systems pertinent to the reason for the visit,
documenting positive findings and pertinent negatives.
⫸ What should be documented in the Objective section of a SOAP
note? Answer: Information observed, lab results, chart notes, and
specific abnormal and relevant negative findings from the physical
exam.
⫸ What systems are typically assessed in the Physical Exam (PE)
section of a SOAP note? Answer: Constitutional, Eyes, ENT/mouth,
Neck, Cardiovascular, Respiratory, GI, GU, Lymphatic,
Musculoskeletal, Skin, Neurological, Psychiatric.
⫸ What is the purpose of the Assessment section in a SOAP note?
Answer: To list and number possible diagnoses based on subjective
and objective data.