NSG 6430 SOAP NOTE SOUTH UNIVERSITY
ACTUAL EXAM PAPER 2026 QUESTIONS
WITH ANSWERS GRADED A+
◍ How is tobacco use quantified?.
Answer: Pack years: (packs per day) x (years smoking).
◍ What is the purpose of an Against Medical Advice (AMA) form?.
Answer: To document a patient's decision to leave a healthcare setting
against the provider's recommendation.
◍ What should be included in the assessment of each current problem?.
Answer: An evaluation of the problem's status and any changes that have
occurred.
◍ What is the importance of organizing findings by system in a physical
exam?.
Answer: It ensures clarity and systematic evaluation of the patient.
◍ What should be included in the general assessment of a patient?.
Answer: Vital signs, pain level, and a list of systems examined.
◍ What are the three important reasons for an AMA form?.
Answer: 1. Acknowledgment of understanding risks, 2. Acceptance of
responsibility, 3. Waiver of provider liability.
◍ What is the formula for writing the 'Objective' section?.
Answer: [Goal] + [Accuracy] + [Cueing Level]
◍ What is the importance of ICD 10 Codes in tests?.
Answer: Tests must be associated with an ICD 10 Code that aligns with the
most specific diagnosis at the time.
◍ What is the purpose of screening questionnaires in clinical documentation?.
, Answer: To identify substance use risks or misuse and victims of intimate
partner violence.
◍ How should a clinician document a patient's chronic conditions?.
Answer: By stating their current status and any necessary follow-up plans.
◍ Why is documentation important in medical records?.
Answer: It ensures provider credibility, serves as a communication tool, aids
in billing/coding, and acts as a legal document.
◍ What is the significance of including the date and results in
labs/diagnostics?.
Answer: To provide context and timeliness of the data being referenced.
◍ What is the SOAP note format?.
Answer: SOAP stands for Subjective, Objective, Assessment, and Plan.
◍ What is the purpose of the 'Assessment' section in a SOAP note?.
Answer: To interpret the data by comparing today's performance to previous
sessions and noting helpful cues.
◍ What does 'Maximal' cue level mean?.
Answer: Frequent, continuous support, such as hand-over-hand assistance.
◍ What should be documented about a patient's sexual history?.
Answer: Gender identity, sexual orientation, number of partners, and
practices.
◍ What is the purpose of the Review of Systems?.
Answer: To inventory the body as a whole and identify symptoms.
◍ What should be done if a recent lab result is not pertinent to the current
encounter?.
Answer: There is no need to include it in the documentation.
◍ What does 'hyperkalemia' refer to in clinical terms?.
Answer: A condition characterized by elevated potassium levels in the
blood.
ACTUAL EXAM PAPER 2026 QUESTIONS
WITH ANSWERS GRADED A+
◍ How is tobacco use quantified?.
Answer: Pack years: (packs per day) x (years smoking).
◍ What is the purpose of an Against Medical Advice (AMA) form?.
Answer: To document a patient's decision to leave a healthcare setting
against the provider's recommendation.
◍ What should be included in the assessment of each current problem?.
Answer: An evaluation of the problem's status and any changes that have
occurred.
◍ What is the importance of organizing findings by system in a physical
exam?.
Answer: It ensures clarity and systematic evaluation of the patient.
◍ What should be included in the general assessment of a patient?.
Answer: Vital signs, pain level, and a list of systems examined.
◍ What are the three important reasons for an AMA form?.
Answer: 1. Acknowledgment of understanding risks, 2. Acceptance of
responsibility, 3. Waiver of provider liability.
◍ What is the formula for writing the 'Objective' section?.
Answer: [Goal] + [Accuracy] + [Cueing Level]
◍ What is the importance of ICD 10 Codes in tests?.
Answer: Tests must be associated with an ICD 10 Code that aligns with the
most specific diagnosis at the time.
◍ What is the purpose of screening questionnaires in clinical documentation?.
, Answer: To identify substance use risks or misuse and victims of intimate
partner violence.
◍ How should a clinician document a patient's chronic conditions?.
Answer: By stating their current status and any necessary follow-up plans.
◍ Why is documentation important in medical records?.
Answer: It ensures provider credibility, serves as a communication tool, aids
in billing/coding, and acts as a legal document.
◍ What is the significance of including the date and results in
labs/diagnostics?.
Answer: To provide context and timeliness of the data being referenced.
◍ What is the SOAP note format?.
Answer: SOAP stands for Subjective, Objective, Assessment, and Plan.
◍ What is the purpose of the 'Assessment' section in a SOAP note?.
Answer: To interpret the data by comparing today's performance to previous
sessions and noting helpful cues.
◍ What does 'Maximal' cue level mean?.
Answer: Frequent, continuous support, such as hand-over-hand assistance.
◍ What should be documented about a patient's sexual history?.
Answer: Gender identity, sexual orientation, number of partners, and
practices.
◍ What is the purpose of the Review of Systems?.
Answer: To inventory the body as a whole and identify symptoms.
◍ What should be done if a recent lab result is not pertinent to the current
encounter?.
Answer: There is no need to include it in the documentation.
◍ What does 'hyperkalemia' refer to in clinical terms?.
Answer: A condition characterized by elevated potassium levels in the
blood.
