NURS 5220 ADULT SOAP NOTE
UNIVERSITY OF TEXAS AT ARLINGTON
FINAL TEST 2026 QUESTIONS WITH
CORRECT ANSWERS GRADED A+
◍ CC: Chief complaint/concern.
Answer: Reason for seeking CareAlways in the patients' words—this sets
the focus of the visit. (may need to teach staff!)Should only be a couple of
sentences."I am here for a physical exam.""I need my cholesterol
checked.""My wife says I forget everything."Ways to elicit CC:• What do
you want to work on today?• What is bothering you the most today?Note all
significant complaintsSeek answer to the question"What underlying
problems or symptoms brought you here?"Determine the duration of the
current illness by asking"How long has this problem been present?"
Or"When did these symptoms begin?"Note age, gender, marital status,
occupation, and previous hospital admissions
◍ ADL.
Answer: activities of daily living
◍ Psychiatric History.
Answer: DatesDiagnosesTreatments, including herbalResults
◍ stat.
Answer: immediately
◍ Beneficence.
Answer: Do good for the patient
◍ Patient History.
Answer: A collection of information about a person's healthIdentify those
, matters the patient defines as problems.Establish a sense of the patient's
reliability.Consider the potential for intentional or unintentional suppression
or underreporting of information.Remain in a constant state of subjective
evaluation of the patient's words and behaviors.Adapt to the modifications
that age, pregnancy, and physical and emotional disabilities mandate
◍ Subjective Data.
Answer: Subjective = States/ SaysSubjective = SymptomsThe purpose of
the subjective interview is to identify PATTERNS
◍ Outline of the History.
Answer: Chief complaint (CC) or the reason for seeking careHistory of
present illness or problem (HPI)Past medical history (PMH)Family history
(FH)Personal and social history (PH/ SH)Review of systems (ROS)
◍ Factors that Enhance Communication.
Answer: Establishing a positive patient relationship depends on
communication built on: Courtesy Comfort Connection Confirmation
ConfidentialityBe Professional: Attire & Response
◍ Order Diagnostic Tests.
Answer: • Need to know what the validity of the test is - Specificity -
Sensitivity• Cost• Don't order a test if you don't know what to do with it!
◍ Sensitive subjects.
Answer: Ensure privacyBe direct and firmDo not apologize for broaching
the issueDo not preachUse language that is understandableDo not push too
hardBe comfortableAlcohol and drug useIntimate partner
violenceSpiritualitySexuality
◍ Effective communication.
Answer: Establishing a positive patient relationship depends on
communication built on:Courtesy Comfort Connection Confirmation
Confidentiality
◍ Sensitive Issues.
Answer: • Alcohol and drug use• Domestic violence• Spirituality• Sexuality
, ◍ Approaching Sensitive Issues.
Answer: • Ensure privacy.• Be direct and firm.• Do not apologize for
broaching the issue.• Do not preach.• Use language that is understandable.•
Do not push too hard.
◍ CTA.
Answer: clear to auscultation
◍ TACE Questionnaire.
Answer: T-How many drinks does it Take to make you feel high?A-Have
people Annoyed you by criticizing your drinking?C-Have you felt you
ought to Cut down on your drinking?E-Have you ever had an Eye‐opener
drink first thing in the morning to steady your nerves or get rid of a
hangover?
◍ Current Health Data.
Answer: • Medications‐prescription, OTC, herbal, vitamins, supplements.
Reason for taking.• Allergies‐foods, meds, environmental. Include type of
reaction to each one. Example: codeine/nausea.• Date, results of last
physical.• Screening tests, results. Includes mmg, pap, c‐scope, PSA, lipids,
etc. • Immunizations - Name and date (or age) - ‐please don't say UTD!
◍ OLDCARTS, COLDSPA.
Answer: Onset, location, duration, characteristics, aggravating, relieving,
treatments, severity
◍ ROS: General Constitutional Symptoms.
Answer: FeverChillsMalaiseFatigabilityNight sweatsSleep
patternsWeight:Average Preferred Present Change
◍ HTN.
Answer: hypertension
◍ ROS: Ears.
Answer: Hearing lossPainDischargeTinnitusVertigo
◍ Sexual history.
UNIVERSITY OF TEXAS AT ARLINGTON
FINAL TEST 2026 QUESTIONS WITH
CORRECT ANSWERS GRADED A+
◍ CC: Chief complaint/concern.
Answer: Reason for seeking CareAlways in the patients' words—this sets
the focus of the visit. (may need to teach staff!)Should only be a couple of
sentences."I am here for a physical exam.""I need my cholesterol
checked.""My wife says I forget everything."Ways to elicit CC:• What do
you want to work on today?• What is bothering you the most today?Note all
significant complaintsSeek answer to the question"What underlying
problems or symptoms brought you here?"Determine the duration of the
current illness by asking"How long has this problem been present?"
Or"When did these symptoms begin?"Note age, gender, marital status,
occupation, and previous hospital admissions
◍ ADL.
Answer: activities of daily living
◍ Psychiatric History.
Answer: DatesDiagnosesTreatments, including herbalResults
◍ stat.
Answer: immediately
◍ Beneficence.
Answer: Do good for the patient
◍ Patient History.
Answer: A collection of information about a person's healthIdentify those
, matters the patient defines as problems.Establish a sense of the patient's
reliability.Consider the potential for intentional or unintentional suppression
or underreporting of information.Remain in a constant state of subjective
evaluation of the patient's words and behaviors.Adapt to the modifications
that age, pregnancy, and physical and emotional disabilities mandate
◍ Subjective Data.
Answer: Subjective = States/ SaysSubjective = SymptomsThe purpose of
the subjective interview is to identify PATTERNS
◍ Outline of the History.
Answer: Chief complaint (CC) or the reason for seeking careHistory of
present illness or problem (HPI)Past medical history (PMH)Family history
(FH)Personal and social history (PH/ SH)Review of systems (ROS)
◍ Factors that Enhance Communication.
Answer: Establishing a positive patient relationship depends on
communication built on: Courtesy Comfort Connection Confirmation
ConfidentialityBe Professional: Attire & Response
◍ Order Diagnostic Tests.
Answer: • Need to know what the validity of the test is - Specificity -
Sensitivity• Cost• Don't order a test if you don't know what to do with it!
◍ Sensitive subjects.
Answer: Ensure privacyBe direct and firmDo not apologize for broaching
the issueDo not preachUse language that is understandableDo not push too
hardBe comfortableAlcohol and drug useIntimate partner
violenceSpiritualitySexuality
◍ Effective communication.
Answer: Establishing a positive patient relationship depends on
communication built on:Courtesy Comfort Connection Confirmation
Confidentiality
◍ Sensitive Issues.
Answer: • Alcohol and drug use• Domestic violence• Spirituality• Sexuality
, ◍ Approaching Sensitive Issues.
Answer: • Ensure privacy.• Be direct and firm.• Do not apologize for
broaching the issue.• Do not preach.• Use language that is understandable.•
Do not push too hard.
◍ CTA.
Answer: clear to auscultation
◍ TACE Questionnaire.
Answer: T-How many drinks does it Take to make you feel high?A-Have
people Annoyed you by criticizing your drinking?C-Have you felt you
ought to Cut down on your drinking?E-Have you ever had an Eye‐opener
drink first thing in the morning to steady your nerves or get rid of a
hangover?
◍ Current Health Data.
Answer: • Medications‐prescription, OTC, herbal, vitamins, supplements.
Reason for taking.• Allergies‐foods, meds, environmental. Include type of
reaction to each one. Example: codeine/nausea.• Date, results of last
physical.• Screening tests, results. Includes mmg, pap, c‐scope, PSA, lipids,
etc. • Immunizations - Name and date (or age) - ‐please don't say UTD!
◍ OLDCARTS, COLDSPA.
Answer: Onset, location, duration, characteristics, aggravating, relieving,
treatments, severity
◍ ROS: General Constitutional Symptoms.
Answer: FeverChillsMalaiseFatigabilityNight sweatsSleep
patternsWeight:Average Preferred Present Change
◍ HTN.
Answer: hypertension
◍ ROS: Ears.
Answer: Hearing lossPainDischargeTinnitusVertigo
◍ Sexual history.
