SOAP NOTE COMPREHENSIVE EXAM
STUDY GUIDE WITH COMPLETE
SOLUTIONS
●● What does the acronym OLD CARTS stand for?
Answer: Onset, Location, Duration, Character, Aggravating/Alleviating
factors, Timing, Severity.
●● What is the purpose of using OLD CARTS in patient assessments?
Answer: To provide a comprehensive approach for assessing a wide
variety of symptoms.
●● What should be documented regarding allergies in patient records?
Answer: Allergies to medications, foods, insects, or environmental
factors, including specific reactions.
●● What information should be recorded about medications?
Answer: Name, dose, route, frequency of use, and any home remedies or
supplements.
●● What should be included in a patient's Past Medical History
(PMHX)?
, Answer: Childhood illnesses, adult illnesses, obstetric/gynecologic
history, and psychiatric conditions.
●● What details should be gathered about a patient's Surgical History
(SHx)?
Answer: Type of operation, indications for surgery, and dates of the
operations.
●● What should be assessed regarding a patient's immunizations?
Answer: Whether the patient is up to date with vaccinations according to
CDC schedules.
●● What is important to ask about during the Last Oral Intake
assessment?
Answer: Food eaten at the most recent meal and relevant details for
patients with abdominal complaints.
●● What should be documented about the Events Leading to
Presentation?
Answer: A frame-by-frame description of what happened leading up to
the patient's illness or injury.
●● What is included in Family History (FHX) documentation?
STUDY GUIDE WITH COMPLETE
SOLUTIONS
●● What does the acronym OLD CARTS stand for?
Answer: Onset, Location, Duration, Character, Aggravating/Alleviating
factors, Timing, Severity.
●● What is the purpose of using OLD CARTS in patient assessments?
Answer: To provide a comprehensive approach for assessing a wide
variety of symptoms.
●● What should be documented regarding allergies in patient records?
Answer: Allergies to medications, foods, insects, or environmental
factors, including specific reactions.
●● What information should be recorded about medications?
Answer: Name, dose, route, frequency of use, and any home remedies or
supplements.
●● What should be included in a patient's Past Medical History
(PMHX)?
, Answer: Childhood illnesses, adult illnesses, obstetric/gynecologic
history, and psychiatric conditions.
●● What details should be gathered about a patient's Surgical History
(SHx)?
Answer: Type of operation, indications for surgery, and dates of the
operations.
●● What should be assessed regarding a patient's immunizations?
Answer: Whether the patient is up to date with vaccinations according to
CDC schedules.
●● What is important to ask about during the Last Oral Intake
assessment?
Answer: Food eaten at the most recent meal and relevant details for
patients with abdominal complaints.
●● What should be documented about the Events Leading to
Presentation?
Answer: A frame-by-frame description of what happened leading up to
the patient's illness or injury.
●● What is included in Family History (FHX) documentation?
