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Week 10 Quiz – SOAP Notes in Healthcare Documentation | Final Exam 2025/2026 | Complete Questions & Correct Answers

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This document contains the complete Week 10 quiz and final exam material on SOAP notes in healthcare documentation, updated for the academic year 2025/2026. It provides all questions with 100% correct answers, covering the structure of SOAP notes, subjective and objective data, assessment, and care planning. It also includes applied examples, clinical scenarios, and key principles such as OLDCARTS, differential diagnoses, and patient history documentation.

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Uploaded on
September 10, 2025
Number of pages
17
Written in
2025/2026
Type
Exam (elaborations)
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Questions & answers

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WEEK 10 QUIZ SOAP NOTES IN HEALTHCARE
DOCUMENTATION FINAL EXAM (LATEST
UPDATE 2025/2026) COMPLETE QUESTIONS
& 100% CORRECT ANSWERS




SOAP note - ANS-A standardized method of
documenting patient encounters in healthcare.


S: Subjective - ANS-Information provided directly by
the patient or caregiver, including symptoms,
history, and personal perceptions of their health
status.


Chief Complaint (CC) - ANS-The primary reason for
the visit.

,History of Present Illness (HPI) - ANS-A detailed
account of the complaint (e.g., onset, duration,
frequency).


Review of Systems (ROS) - ANS-A systematic
review of body systems.


Past Medical History (PMH) - ANS-Previous illnesses,
hospitalizations, surgeries.


Social History (SH) - ANS-Lifestyle, occupation,
habits (e.g., smoking, alcohol use).


Family History (FH) - ANS-Health history of close
relatives.

, O: Objective - ANS-Observable, measurable, or
quantifiable data obtained by the clinician through
physical exams, laboratory results, and imaging.


Vital Signs - ANS-Blood pressure, heart rate,
respiratory rate, temperature.


Physical Exam Findings - ANS-Inspection, palpation,
percussion, auscultation.


Lab Results - ANS-Blood tests, urine analysis.


Imaging Results - ANS-X-rays, CT scans, MRI.


A: Assessment - ANS-The clinician's diagnosis or
impression based on subjective and objective data.


Primary Diagnosis - ANS-The most likely diagnosis.

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