NSG6435 FINAL CERTIFICATION
EVALUATION TESTED QUESTIONS AND
ANSWERS COMPLETE REVIEW
●● Objective (SOAP note)
Answer: Observed/measured findings
Includes:
• Vital signs
• Physical exam findings
• Lab results
• Diagnostic tests
●● Assessment (SOAP note)
Answer: • Medical diagnosis
• Differential diagnoses
• Clinical impression
●● Plan (SOAP note)
Answer: Treatment plan:
• Medications
,• Labs
• Imaging
• Referrals
• Patient education
• Follow-up
●● Types of SOAP Notes
Answer: Comprehensive
Full history + full physical exam.
Used for:
• New patient visits
• Annual exams
Focused
Problem-specific exam.
Used for:
• Follow-up
• Chronic disease management
,Episodic
Single acute complaint.
Example:
• Sore throat
• Ear pain
●● HISTORY OF PRESENT ILLNESS (HPI)
Answer: OLDCARTS (onset-location-duration-character-
allieving/aggravating-time-severity)
●● SUBJECTIVE vs OBJECTIVE DATA
Answer: Subjective
Patient statements.
Example:
• "My chest hurts"
• "I feel dizzy"
• "I have a headache"
, Objective
Clinician findings.
Example:
• BP 150/90
• Wheezing
• Rash on chest
●● SKILLED INTERVIEWING
Answer: Key components:
• Open-ended questions
• Active listening
• Empathy
• Clarification
• Cultural humility
●● NEUROLOGICAL SYSTEM-CNS
Answer: Includes:
• Brain
• Spinal cord
EVALUATION TESTED QUESTIONS AND
ANSWERS COMPLETE REVIEW
●● Objective (SOAP note)
Answer: Observed/measured findings
Includes:
• Vital signs
• Physical exam findings
• Lab results
• Diagnostic tests
●● Assessment (SOAP note)
Answer: • Medical diagnosis
• Differential diagnoses
• Clinical impression
●● Plan (SOAP note)
Answer: Treatment plan:
• Medications
,• Labs
• Imaging
• Referrals
• Patient education
• Follow-up
●● Types of SOAP Notes
Answer: Comprehensive
Full history + full physical exam.
Used for:
• New patient visits
• Annual exams
Focused
Problem-specific exam.
Used for:
• Follow-up
• Chronic disease management
,Episodic
Single acute complaint.
Example:
• Sore throat
• Ear pain
●● HISTORY OF PRESENT ILLNESS (HPI)
Answer: OLDCARTS (onset-location-duration-character-
allieving/aggravating-time-severity)
●● SUBJECTIVE vs OBJECTIVE DATA
Answer: Subjective
Patient statements.
Example:
• "My chest hurts"
• "I feel dizzy"
• "I have a headache"
, Objective
Clinician findings.
Example:
• BP 150/90
• Wheezing
• Rash on chest
●● SKILLED INTERVIEWING
Answer: Key components:
• Open-ended questions
• Active listening
• Empathy
• Clarification
• Cultural humility
●● NEUROLOGICAL SYSTEM-CNS
Answer: Includes:
• Brain
• Spinal cord
