NURS 5220 SOAP NOTE ASSIGNMENT 1 | 2026
UPDATED | WITH COMPLETE SOLUTIONS - UTA
Actual Exam 2026/2027 | Complete Exam-Style Questions
with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
SOAP Note Structure and Documentation Standards
Q1: When documenting a patient's exact statement, "I feel a sharp, stabbing pain in my
chest when I take a deep breath," which section of the SOAP note is the most appropriate
place for this quote?
A. Objective
B. Assessment
C. Subjective [CORRECT]
D. Plan
Correct Answer: C
Rationale: The best answer is Subjective, as this section is specifically designated for the
patient's own words, reported symptoms, and personal health history.
Q2: A nurse practitioner documents, "Patient appears anxious, pacing the room, and has a
respiratory rate of 24 breaths per minute." Where does this documentation primarily
belong?
A. Subjective
B. Objective [CORRECT]
C. Assessment
D. Plan
Correct Answer: B
Rationale: This choice is correct because observable behaviors and measurable vital signs
are considered objective data that can be independently verified by the clinician.
Q3: Which of the following statements represents a common documentation error when
writing the Assessment section of a SOAP note?
A. Including a list of prescribed medications and their dosages. [CORRECT]
B. Stating the primary diagnosis followed by differential diagnoses.
C. Summarizing the clinical reasoning based on subjective and objective findings.
D. Linking the patient's symptoms to a specific pathophysiological process.
Correct Answer: A
Rationale: This choice is correct because listing medications and dosages belongs in the Plan
section, not the Assessment, which should be reserved for diagnoses and clinical reasoning.
Q4: From a legal and risk management perspective, what is the most critical rule when
correcting an error in a patient's electronic health record?
A. Erase the original entry completely to avoid confusion.
, B. Draw a single line through the error, write "error," initial, date, and add the correct
information. [CORRECT]
C. Use white-out or digital deletion tools to maintain a clean chart.
D. Leave the error as is and add a note in the next visit's SOAP note.
Correct Answer: B
Rationale: This aligns with legal documentation standards, which require that original
entries remain legible while clearly indicating the correction, the date, and the author's
identity.
Q5: Which component of the History of Present Illness (HPI) is missing from this statement:
"The patient reports a headache that started yesterday"?
A. Location
B. Duration
C. Quality
D. Context and modifying factors [CORRECT]
Correct Answer: D
Rationale: The best answer is context and modifying factors, as the statement provides
location (head), onset/duration (yesterday), but fails to mention what makes it better or
worse or the circumstances of its onset.
Q6: When determining the level of Medical Decision Making (MDM) for billing purposes,
which of the following is NOT one of the three core elements evaluated?
A. Number and complexity of problems addressed.
B. Amount and complexity of data to be reviewed.
C. Patient's socioeconomic status and insurance type. [CORRECT]
D. Risk of complications, morbidity, or mortality.
Correct Answer: C
Rationale: This choice is correct because MDM is strictly based on clinical complexity, data
reviewed, and risk, whereas socioeconomic status is not a factor in E/M coding guidelines.
Q7: A student writes, "Will prescribe ibuprofen 600 mg every 8 hours as needed for pain." In
which section of the SOAP note should this statement be placed?
A. Subjective
B. Objective
C. Assessment
D. Plan [CORRECT]
Correct Answer: D
Rationale: This aligns with the principle that the Plan section must outline all actionable
steps, including pharmacological treatments, prescriptions, and patient instructions.
Q8: A patient mentions during the interview, "My mother had a myocardial infarction at age
50." Where is this information most appropriately documented?
A. History of Present Illness
B. Past Medical History
C. Family History [CORRECT]
D. Review of Systems
Correct Answer: C
UPDATED | WITH COMPLETE SOLUTIONS - UTA
Actual Exam 2026/2027 | Complete Exam-Style Questions
with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
SOAP Note Structure and Documentation Standards
Q1: When documenting a patient's exact statement, "I feel a sharp, stabbing pain in my
chest when I take a deep breath," which section of the SOAP note is the most appropriate
place for this quote?
A. Objective
B. Assessment
C. Subjective [CORRECT]
D. Plan
Correct Answer: C
Rationale: The best answer is Subjective, as this section is specifically designated for the
patient's own words, reported symptoms, and personal health history.
Q2: A nurse practitioner documents, "Patient appears anxious, pacing the room, and has a
respiratory rate of 24 breaths per minute." Where does this documentation primarily
belong?
A. Subjective
B. Objective [CORRECT]
C. Assessment
D. Plan
Correct Answer: B
Rationale: This choice is correct because observable behaviors and measurable vital signs
are considered objective data that can be independently verified by the clinician.
Q3: Which of the following statements represents a common documentation error when
writing the Assessment section of a SOAP note?
A. Including a list of prescribed medications and their dosages. [CORRECT]
B. Stating the primary diagnosis followed by differential diagnoses.
C. Summarizing the clinical reasoning based on subjective and objective findings.
D. Linking the patient's symptoms to a specific pathophysiological process.
Correct Answer: A
Rationale: This choice is correct because listing medications and dosages belongs in the Plan
section, not the Assessment, which should be reserved for diagnoses and clinical reasoning.
Q4: From a legal and risk management perspective, what is the most critical rule when
correcting an error in a patient's electronic health record?
A. Erase the original entry completely to avoid confusion.
, B. Draw a single line through the error, write "error," initial, date, and add the correct
information. [CORRECT]
C. Use white-out or digital deletion tools to maintain a clean chart.
D. Leave the error as is and add a note in the next visit's SOAP note.
Correct Answer: B
Rationale: This aligns with legal documentation standards, which require that original
entries remain legible while clearly indicating the correction, the date, and the author's
identity.
Q5: Which component of the History of Present Illness (HPI) is missing from this statement:
"The patient reports a headache that started yesterday"?
A. Location
B. Duration
C. Quality
D. Context and modifying factors [CORRECT]
Correct Answer: D
Rationale: The best answer is context and modifying factors, as the statement provides
location (head), onset/duration (yesterday), but fails to mention what makes it better or
worse or the circumstances of its onset.
Q6: When determining the level of Medical Decision Making (MDM) for billing purposes,
which of the following is NOT one of the three core elements evaluated?
A. Number and complexity of problems addressed.
B. Amount and complexity of data to be reviewed.
C. Patient's socioeconomic status and insurance type. [CORRECT]
D. Risk of complications, morbidity, or mortality.
Correct Answer: C
Rationale: This choice is correct because MDM is strictly based on clinical complexity, data
reviewed, and risk, whereas socioeconomic status is not a factor in E/M coding guidelines.
Q7: A student writes, "Will prescribe ibuprofen 600 mg every 8 hours as needed for pain." In
which section of the SOAP note should this statement be placed?
A. Subjective
B. Objective
C. Assessment
D. Plan [CORRECT]
Correct Answer: D
Rationale: This aligns with the principle that the Plan section must outline all actionable
steps, including pharmacological treatments, prescriptions, and patient instructions.
Q8: A patient mentions during the interview, "My mother had a myocardial infarction at age
50." Where is this information most appropriately documented?
A. History of Present Illness
B. Past Medical History
C. Family History [CORRECT]
D. Review of Systems
Correct Answer: C
