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.