NR 509 SOAP Note Week 1 Course Advanced Physical
Assessment (NR-509) - Chamberlain College Of Nursing
(NR 509 Advanced Physical Assessment)
SECTION I: SOAP Note Structure & Components
1. The SOAP note format was originally developed by which physician as part of the problem-
oriented medical record?
A. Dr. William Osler
B. Dr. Lawrence Weed
C. Dr. Virginia Henderson
D. Dr. Hildegard Peplau
Correct Answer: B
Rationale: The SOAP note structure was developed by Dr. Lawrence Weed approximately 50
years ago as part of the problem-oriented medical record system . This framework organized
patient information into Subjective, Objective, Assessment, and Plan sections, providing a
standardized approach to clinical documentation that remains the standard across healthcare
settings.
2. In the SOAP note format, which section exclusively contains information the patient or
patient representative tells you?
A. Objective
B. Assessment
C. Subjective
D. Plan
Correct Answer: C
Rationale: The Subjective section captures what the patient tells you, including the chief
complaint, history of present illness, review of systems, past medical history, social history, and
medications . This includes direct quotes from the patient and their descriptions of symptoms,
which cannot be independently verified by the clinician.
,3. A nurse practitioner documents the following: "Abdomen soft, non-tender to palpation in
all four quadrants; bowel sounds present x4." This information belongs in which section of
the SOAP note?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: B
Rationale: Objective data consists of measurable, observable, and verifiable findings
obtained during the physical examination . Palpation findings, auscultation results, vital signs,
and laboratory values are all objective data that the clinician directly observes or measures.
4. Which of the following is an example of subjective data?
A. Temperature of 38.2°C
B. Blood pressure of 146/92 mmHg
C. Patient reports nausea after eating
D. 2.5 cm scar on the right forearm
Correct Answer: C
Rationale: Subjective information comes from what the patient reports, including
symptoms, concerns, and perceptions . Patient-reported nausea is a symptom that cannot be
directly measured by the clinician. Temperature, blood pressure, and visible scars are all
objective findings that can be verified through measurement or observation.
5. The Assessment section of a SOAP note serves which primary purpose?
A. Recording only the patient's chief complaint
B. Listing medications prescribed during the visit
C. Synthesizing subjective and objective findings into clinical impressions and differential
diagnoses
D. Documenting follow-up instructions
Correct Answer: C
, Rationale: The Assessment section represents the clinician's interpretation of collected
information and typically includes the working diagnosis and relevant differential diagnoses .
This is the cognitive core of the note where clinical reasoning transforms data into diagnostic
conclusions.
6. A SOAP note is being written for a patient with chest pain. Which entry represents the BEST
example of documented Objective data?
A. "The patient states the pain is a 7/10"
B. "The patient appears anxious and is sweating heavily"
C. "Patient reports chest pressure that began 2 hours ago"
D. "Patient likely has gastroenteritis versus cholecystitis"
Correct Answer: B
Rationale: Objective data includes observable findings such as the patient's appearance and
physical signs . "Appears anxious and sweating heavily" describes what the clinician directly
observes. Pain rating and symptom description are subjective (patient-reported), and diagnostic
impressions belong in the Assessment section.
7. Which mnemonic is most appropriate for structuring the History of Present Illness (HPI) in a
SOAP note?
A. PQRST
B. OLDCARTS
C. SOCRATES
D. ABCDE
Correct Answer: B
Rationale: OLDCARTS is the standard mnemonic for comprehensive HPI documentation in
advanced physical assessment . It stands for Onset, Location, Duration, Character,
Aggravating/Associated factors, Relieving factors, Temporal factors, and Severity. This systematic
approach ensures all critical elements of the patient's symptom history are captured.
8. In the SOAP note template used in NR 509, which section includes vital signs, general
survey, and physical examination findings?
, A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: B
Rationale: The Objective section is for "what you observe, measure, and find on exam,"
including vital signs, general survey, physical exam findings by system, and diagnostic data such
as labs and imaging . These are all measurable and verifiable findings.
9. A nurse practitioner writes in a SOAP note: "Patient likely has community-acquired
pneumonia versus acute bronchitis." This statement belongs in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: C
Rationale: The Assessment section contains clinical reasoning, problem lists, differential
diagnoses, and the primary diagnosis with rationale . Statements of diagnostic possibility
represent the clinician's interpretation of the collected data.
10. Which of the following is NOT a component of the Subjective section of a SOAP note?
A. Chief complaint
B. Review of systems
C. Physical examination findings
D. Past medical history
Correct Answer: C
Rationale: Physical examination findings are objective data obtained through inspection,
palpation, percussion, and auscultation . The Subjective section includes the chief complaint,
HPI (OLDCARTS), review of systems, past medical/surgical history, family history, social history,
medications, and allergies.
Assessment (NR-509) - Chamberlain College Of Nursing
(NR 509 Advanced Physical Assessment)
SECTION I: SOAP Note Structure & Components
1. The SOAP note format was originally developed by which physician as part of the problem-
oriented medical record?
A. Dr. William Osler
B. Dr. Lawrence Weed
C. Dr. Virginia Henderson
D. Dr. Hildegard Peplau
Correct Answer: B
Rationale: The SOAP note structure was developed by Dr. Lawrence Weed approximately 50
years ago as part of the problem-oriented medical record system . This framework organized
patient information into Subjective, Objective, Assessment, and Plan sections, providing a
standardized approach to clinical documentation that remains the standard across healthcare
settings.
2. In the SOAP note format, which section exclusively contains information the patient or
patient representative tells you?
A. Objective
B. Assessment
C. Subjective
D. Plan
Correct Answer: C
Rationale: The Subjective section captures what the patient tells you, including the chief
complaint, history of present illness, review of systems, past medical history, social history, and
medications . This includes direct quotes from the patient and their descriptions of symptoms,
which cannot be independently verified by the clinician.
,3. A nurse practitioner documents the following: "Abdomen soft, non-tender to palpation in
all four quadrants; bowel sounds present x4." This information belongs in which section of
the SOAP note?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: B
Rationale: Objective data consists of measurable, observable, and verifiable findings
obtained during the physical examination . Palpation findings, auscultation results, vital signs,
and laboratory values are all objective data that the clinician directly observes or measures.
4. Which of the following is an example of subjective data?
A. Temperature of 38.2°C
B. Blood pressure of 146/92 mmHg
C. Patient reports nausea after eating
D. 2.5 cm scar on the right forearm
Correct Answer: C
Rationale: Subjective information comes from what the patient reports, including
symptoms, concerns, and perceptions . Patient-reported nausea is a symptom that cannot be
directly measured by the clinician. Temperature, blood pressure, and visible scars are all
objective findings that can be verified through measurement or observation.
5. The Assessment section of a SOAP note serves which primary purpose?
A. Recording only the patient's chief complaint
B. Listing medications prescribed during the visit
C. Synthesizing subjective and objective findings into clinical impressions and differential
diagnoses
D. Documenting follow-up instructions
Correct Answer: C
, Rationale: The Assessment section represents the clinician's interpretation of collected
information and typically includes the working diagnosis and relevant differential diagnoses .
This is the cognitive core of the note where clinical reasoning transforms data into diagnostic
conclusions.
6. A SOAP note is being written for a patient with chest pain. Which entry represents the BEST
example of documented Objective data?
A. "The patient states the pain is a 7/10"
B. "The patient appears anxious and is sweating heavily"
C. "Patient reports chest pressure that began 2 hours ago"
D. "Patient likely has gastroenteritis versus cholecystitis"
Correct Answer: B
Rationale: Objective data includes observable findings such as the patient's appearance and
physical signs . "Appears anxious and sweating heavily" describes what the clinician directly
observes. Pain rating and symptom description are subjective (patient-reported), and diagnostic
impressions belong in the Assessment section.
7. Which mnemonic is most appropriate for structuring the History of Present Illness (HPI) in a
SOAP note?
A. PQRST
B. OLDCARTS
C. SOCRATES
D. ABCDE
Correct Answer: B
Rationale: OLDCARTS is the standard mnemonic for comprehensive HPI documentation in
advanced physical assessment . It stands for Onset, Location, Duration, Character,
Aggravating/Associated factors, Relieving factors, Temporal factors, and Severity. This systematic
approach ensures all critical elements of the patient's symptom history are captured.
8. In the SOAP note template used in NR 509, which section includes vital signs, general
survey, and physical examination findings?
, A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: B
Rationale: The Objective section is for "what you observe, measure, and find on exam,"
including vital signs, general survey, physical exam findings by system, and diagnostic data such
as labs and imaging . These are all measurable and verifiable findings.
9. A nurse practitioner writes in a SOAP note: "Patient likely has community-acquired
pneumonia versus acute bronchitis." This statement belongs in which section?
A. Subjective
B. Objective
C. Assessment
D. Plan
Correct Answer: C
Rationale: The Assessment section contains clinical reasoning, problem lists, differential
diagnoses, and the primary diagnosis with rationale . Statements of diagnostic possibility
represent the clinician's interpretation of the collected data.
10. Which of the following is NOT a component of the Subjective section of a SOAP note?
A. Chief complaint
B. Review of systems
C. Physical examination findings
D. Past medical history
Correct Answer: C
Rationale: Physical examination findings are objective data obtained through inspection,
palpation, percussion, and auscultation . The Subjective section includes the chief complaint,
HPI (OLDCARTS), review of systems, past medical/surgical history, family history, social history,
medications, and allergies.
