SOAP NOTE EXAM SCRIPT WITH VERIFIED
QUESTIONS AND ANSWERS
●● SOAP note
Answer: A method of documentation for providers of the patient's
encounter, electronically recorded in a patient's EMR/EHR
●● Subjective component
Answer: Includes information from the patient or their family regarding
symptoms and reasons for seeking evaluation
●● Chief complaint
Answer: The main reason for the patient's visit or the primary concern
they have
●● History of present illness (HPI)
Answer: A detailed narrative of the patient's symptoms, their onset,
duration, severity, and any factors that aggravate or alleviate them
●● Past medical history
Answer: Information about the patient's past medical conditions,
surgeries, and significant health events
,●● Medications
Answer: A list of current medications the patient is taking, including
dosages and frequencies
●● Allergies
Answer: Any known allergies to medications, foods, or environmental
factors
●● Social history
Answer: Information about the patient's lifestyle, including habits such
as smoking, alcohol use, and exercise
●● Family history
Answer: Details about the health conditions of the patient's immediate
family members
●● Objective component
Answer: Includes information from the provider that can be measured,
seen, heard, touched, felt, or smelled
●● Vital signs
Answer: Measurements such as blood pressure, heart rate, respiratory
rate, temperature, and sometimes oxygen saturation
,●● Physical examination
Answer: Findings from the examination of various body systems,
including general appearance and specific organ systems
●● Laboratory data
Answer: Results of diagnostic tests such as blood tests, imaging studies,
and other relevant investigations
●● Assessment component
Answer: The diagnosis of the patient's condition based on the subjective
and objective information gathered
●● Diagnosis
Answer: A statement of the healthcare provider's assessment based on
the information gathered
●● Differential diagnosis
Answer: A list of potential diagnoses considered by the provider,
typically ranked by likelihood
●● Assessment of progress
Answer: Evaluation of any changes or developments in the patient's
condition since the client's chief complaint
, ●● Plan component
Answer: What the provider plans to do with the patient moving forward,
including long-term care
●● Treatment plan
Answer: Specific steps and interventions planned to address the patient's
condition
●● Education
Answer: Information provided to the patient about their condition,
treatment options, and self-care measures
●● Follow-up
Answer: Plans for subsequent visits or monitoring, including scheduling
follow-up appointments or referrals to specialists
●● Prognosis
Answer: Discussion of the expected course of the patient's condition and
potential outcomes
●● HPI elements
Answer: Location/Radiation, Context, Duration, Onset, Character,
Related Symptoms, Alleviating/Aggravating Factors, Severity
QUESTIONS AND ANSWERS
●● SOAP note
Answer: A method of documentation for providers of the patient's
encounter, electronically recorded in a patient's EMR/EHR
●● Subjective component
Answer: Includes information from the patient or their family regarding
symptoms and reasons for seeking evaluation
●● Chief complaint
Answer: The main reason for the patient's visit or the primary concern
they have
●● History of present illness (HPI)
Answer: A detailed narrative of the patient's symptoms, their onset,
duration, severity, and any factors that aggravate or alleviate them
●● Past medical history
Answer: Information about the patient's past medical conditions,
surgeries, and significant health events
,●● Medications
Answer: A list of current medications the patient is taking, including
dosages and frequencies
●● Allergies
Answer: Any known allergies to medications, foods, or environmental
factors
●● Social history
Answer: Information about the patient's lifestyle, including habits such
as smoking, alcohol use, and exercise
●● Family history
Answer: Details about the health conditions of the patient's immediate
family members
●● Objective component
Answer: Includes information from the provider that can be measured,
seen, heard, touched, felt, or smelled
●● Vital signs
Answer: Measurements such as blood pressure, heart rate, respiratory
rate, temperature, and sometimes oxygen saturation
,●● Physical examination
Answer: Findings from the examination of various body systems,
including general appearance and specific organ systems
●● Laboratory data
Answer: Results of diagnostic tests such as blood tests, imaging studies,
and other relevant investigations
●● Assessment component
Answer: The diagnosis of the patient's condition based on the subjective
and objective information gathered
●● Diagnosis
Answer: A statement of the healthcare provider's assessment based on
the information gathered
●● Differential diagnosis
Answer: A list of potential diagnoses considered by the provider,
typically ranked by likelihood
●● Assessment of progress
Answer: Evaluation of any changes or developments in the patient's
condition since the client's chief complaint
, ●● Plan component
Answer: What the provider plans to do with the patient moving forward,
including long-term care
●● Treatment plan
Answer: Specific steps and interventions planned to address the patient's
condition
●● Education
Answer: Information provided to the patient about their condition,
treatment options, and self-care measures
●● Follow-up
Answer: Plans for subsequent visits or monitoring, including scheduling
follow-up appointments or referrals to specialists
●● Prognosis
Answer: Discussion of the expected course of the patient's condition and
potential outcomes
●● HPI elements
Answer: Location/Radiation, Context, Duration, Onset, Character,
Related Symptoms, Alleviating/Aggravating Factors, Severity
