NSG 6430 SOAP NOTE SOUTH UNIVERSITY
PRACTICE EXAMINATION 2026
QUESTIONS WITH ANSWERS GRADED A+
◍ What are the three P's that must be included in the assessment?.
Answer: Problems, Progress, and Potential.
◍ What is the purpose of activity analysis in occupational therapy?.
Answer: To orient to the goals of activity and minimize description of the
activity itself.
◍ What is included in the Review of Systems (ROS)?.
Answer: The ROS is a systematic review of each body system to identify
any additional symptoms or concerns not previously mentioned.
◍ What is a 'would benefit from' statement?.
Answer: A justification for ongoing OT that indicates the need for skilled
intervention.
◍ What is included in the Chief Complaint (CC)?.
Answer: The Chief Complaint is a brief statement of the primary reason the
patient is seeking medical care.
◍ What should be documented regarding barriers to interventions?.
Answer: Any barriers that affected the interventions or outcomes should be
recorded.
◍ What does the 'A' in SOAP notes stand for?.
Answer: Assessment, which demonstrates clinical reasoning and interprets
the data from the 'S' and 'O' sections.
◍ What should be included in the Surgical History?.
Answer: Surgical History should document any past surgeries, including
, dates, types of operations, and any complications.
◍ What is a SOAP note?.
Answer: A structured method of documentation used by healthcare
providers to record patient information, consisting of Subjective, Objective,
Assessment, and Plan sections.
◍ What is the purpose of documenting a patient's Social History?.
Answer: Social History provides context about the patient's lifestyle,
including their living situation, occupation, and social support.
◍ What is the purpose of the Objective section in a SOAP note?.
Answer: To record all data obtained during the client's occupational therapy
session.
◍ What is the purpose of documenting potential in OT?.
Answer: To highlight the client's strengths and the need for continued
intervention.
◍ How should functional performance be documented in the Objective
section?.
Answer: By providing an overview of key deficits affecting the client's
performance and using performance skill terminology.
◍ What is the importance of minimizing description in documentation?.
Answer: To focus on the client's engagement and the therapeutic purpose of
the activity.
◍ What does 'Objective' refer to in a SOAP note?.
Answer: The 'Objective' section contains measurable and observable
findings from the physical examination and diagnostic tests.
◍ What is the role of the OTA in making observations?.
Answer: To make skilled observations that are detailed and specific, based
on training.
◍ What are the 3 P's in organizing the Assessment section?.
Answer: Problem, Progress, Plan.
PRACTICE EXAMINATION 2026
QUESTIONS WITH ANSWERS GRADED A+
◍ What are the three P's that must be included in the assessment?.
Answer: Problems, Progress, and Potential.
◍ What is the purpose of activity analysis in occupational therapy?.
Answer: To orient to the goals of activity and minimize description of the
activity itself.
◍ What is included in the Review of Systems (ROS)?.
Answer: The ROS is a systematic review of each body system to identify
any additional symptoms or concerns not previously mentioned.
◍ What is a 'would benefit from' statement?.
Answer: A justification for ongoing OT that indicates the need for skilled
intervention.
◍ What is included in the Chief Complaint (CC)?.
Answer: The Chief Complaint is a brief statement of the primary reason the
patient is seeking medical care.
◍ What should be documented regarding barriers to interventions?.
Answer: Any barriers that affected the interventions or outcomes should be
recorded.
◍ What does the 'A' in SOAP notes stand for?.
Answer: Assessment, which demonstrates clinical reasoning and interprets
the data from the 'S' and 'O' sections.
◍ What should be included in the Surgical History?.
Answer: Surgical History should document any past surgeries, including
, dates, types of operations, and any complications.
◍ What is a SOAP note?.
Answer: A structured method of documentation used by healthcare
providers to record patient information, consisting of Subjective, Objective,
Assessment, and Plan sections.
◍ What is the purpose of documenting a patient's Social History?.
Answer: Social History provides context about the patient's lifestyle,
including their living situation, occupation, and social support.
◍ What is the purpose of the Objective section in a SOAP note?.
Answer: To record all data obtained during the client's occupational therapy
session.
◍ What is the purpose of documenting potential in OT?.
Answer: To highlight the client's strengths and the need for continued
intervention.
◍ How should functional performance be documented in the Objective
section?.
Answer: By providing an overview of key deficits affecting the client's
performance and using performance skill terminology.
◍ What is the importance of minimizing description in documentation?.
Answer: To focus on the client's engagement and the therapeutic purpose of
the activity.
◍ What does 'Objective' refer to in a SOAP note?.
Answer: The 'Objective' section contains measurable and observable
findings from the physical examination and diagnostic tests.
◍ What is the role of the OTA in making observations?.
Answer: To make skilled observations that are detailed and specific, based
on training.
◍ What are the 3 P's in organizing the Assessment section?.
Answer: Problem, Progress, Plan.
