SOAP Notes and Cultural Competency Exam
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(Latest Update 2026) UPDATE!!
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Focused Exam -Patient encounter where the "focus" is on the
patient's chief complaint
-are documented in a SOAP NOTE
-SOAP notes are not complete History & Physicals
-perform this
-problem oriented
-only ask questions related to chief complaint
-what brings patient to this visit
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,5/1/26, 9:23 AM SOAP Notes and Cultural Competency Exam Questions and answers with verified Answers (Latest Update 2026) UPDATE!! Flashca…
S Anything the patient or family tell you
Chief Complaint & Duration
HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have
significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of
concern & Utilize CAGE) Do you drink alcohol?
How much?
Living environment: (Ask If there is an area of
concern) - do you feel safe, are you afraid in your
own home?
-ab pain we don't care about cataract surgery, not
relevant
CAGE Cutting down, annoyance when asked about
drinking, Guilt do you feel guilty about it, Eye
opener - to get you going in the morning
-if response is 2/4 needs further evaluation
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Chief Complaint Limited to one complaint, most pressing
Brief- as few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is
the main thing, most important
-anyone who presents with painful urination always
question STD/STI, ask about discharge, sexual
activity, check back for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's
terminology
-provides "title" for the encounter
-what brings you to the office? why did the
symptom bring you to the office?
-describe it like you would to a relative or neighbor
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, 5/1/26, 9:23 AM SOAP Notes and Cultural Competency Exam Questions and answers with verified Answers (Latest Update 2026) UPDATE!! Flashca…
History of Present Illness -Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the
patient's responses.
-You guide the patient to answer your questions.
-Include SLIDTA
-Difference between SOAP and H&P: associated
symptoms go in body of HPI
-This is a 52 year old African American male who
presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as
reports..........
Patients' negative response to ROS is recorded as
denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come
to a diagnosis
-90% of the time the diagnosis is made by the end
of the HPI (assuming that you have asked the
correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
-"Reports not sexually active." Easy way out for
course
-In the body of this in a soap note: may include
medications, past medical, past surgical and social
if relevant to chief complaint - or can write below
this
-Include reverent review of systems
-Must write year when meds were started - must
include, if they don't know write "unknown start
date"
-Drug, food, seasonal and environmental allergies
- latex
-Smoking - Do you smoke? Have you ever smoked
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