©THEBRIGHT EXAM STUDY SOLUTIONS 8/26/2024 11:32 AM
SOAP Note. Exam Questions And
Correct Answers
What are the BOC practice domains? - answer✔✔Injury/Illness Prevention&Wellness Protection
Clinical Evaluation and Diagnosis
Immediate and Emergency Care
Treatment and Rehabilitation
Organizational and Professional Health and Well-being
What does SOAP mean? - answer✔✔Subjective
Objective
Assessment
Plan
Who introduced the SOAP note format? - answer✔✔Dr. Lawrence Weed; created it as a system
to organize medical records.
What are the 3 different types of SOAP notes? - answer✔✔Initial
Progress
Discharge
Initial - answer✔✔Written after the initial patient assessment
Progress - answer✔✔Written periodically, reporting the results of reassessment
Discharge - answer✔✔Written at the time that therapy is discontinued
Accuracy of Writing a Medical Record - answer✔✔Never record falsely, exaggerate, or make up
data
Brevity of Writing a Medical Record - answer✔✔Information should be stated concisely.
, ©THEBRIGHT EXAM STUDY SOLUTIONS 8/26/2024 11:32 AM
Important to be consistent in style to avoid confusion and to be consistent with policies of the
facility.
Abbreviations can help with brevity.
Clarity of Writing a Medical Record - answer✔✔Avoid vague terminology.
Handwriting needs to be legible; the purpose of writing notes is defeated if the notes cannot be
easily read.
Punctuation of Writing a Medical Record: Hyphen - answer✔✔Should be avoided because they
can be confused with minus signs used in muscle grades or negative grades.
One exception is the common use of a hyphen instead of the word through (AROM:0-48
degrees)
Punctuation of Writing a Medical Record: Semicolon - answer✔✔Instead of overusing "states"
in the subjective part of the note, a semicolon can be used to connect two related statements
(States position of comfort for sleep is on right side; pain does not awaken Pt at night.)
Punctuation of Writing a Medical Record: Colon - answer✔✔Can be used instead of "is"
(AROM R Shoulder flexion: 0-90 degrees)
Correcting Errors in Writing a Medical Record - answer✔✔"White out" should not be used on a
medical record.
Proper method of correcting a mistake is to put a line through the error, write "error" above the
mistake, date and initial it.
Signing your notes in Writing a Medical Record - answer✔✔You should sign every entry that
you make into the medical record
Referring to Yourself - answer✔✔Notes discuss the patient and not the therapist.
All references should be in third person (AT, PT, etc.)
Blank or empty Lines - answer✔✔Lines should not be left between one entry and another, nor
should empty lines be left within a single entry.
Empty lines are area in which another person could falsify information already charted.
Writing orders in charts - answer✔✔When a physician gives an order it maybe your
responsibility for writing it in the chart.
Date/Time/Order
Stating the Problem - answer✔✔The problem part of the note can be stated as the patient's chief
complaint, the dx, or loss of function.
SOAP Note. Exam Questions And
Correct Answers
What are the BOC practice domains? - answer✔✔Injury/Illness Prevention&Wellness Protection
Clinical Evaluation and Diagnosis
Immediate and Emergency Care
Treatment and Rehabilitation
Organizational and Professional Health and Well-being
What does SOAP mean? - answer✔✔Subjective
Objective
Assessment
Plan
Who introduced the SOAP note format? - answer✔✔Dr. Lawrence Weed; created it as a system
to organize medical records.
What are the 3 different types of SOAP notes? - answer✔✔Initial
Progress
Discharge
Initial - answer✔✔Written after the initial patient assessment
Progress - answer✔✔Written periodically, reporting the results of reassessment
Discharge - answer✔✔Written at the time that therapy is discontinued
Accuracy of Writing a Medical Record - answer✔✔Never record falsely, exaggerate, or make up
data
Brevity of Writing a Medical Record - answer✔✔Information should be stated concisely.
, ©THEBRIGHT EXAM STUDY SOLUTIONS 8/26/2024 11:32 AM
Important to be consistent in style to avoid confusion and to be consistent with policies of the
facility.
Abbreviations can help with brevity.
Clarity of Writing a Medical Record - answer✔✔Avoid vague terminology.
Handwriting needs to be legible; the purpose of writing notes is defeated if the notes cannot be
easily read.
Punctuation of Writing a Medical Record: Hyphen - answer✔✔Should be avoided because they
can be confused with minus signs used in muscle grades or negative grades.
One exception is the common use of a hyphen instead of the word through (AROM:0-48
degrees)
Punctuation of Writing a Medical Record: Semicolon - answer✔✔Instead of overusing "states"
in the subjective part of the note, a semicolon can be used to connect two related statements
(States position of comfort for sleep is on right side; pain does not awaken Pt at night.)
Punctuation of Writing a Medical Record: Colon - answer✔✔Can be used instead of "is"
(AROM R Shoulder flexion: 0-90 degrees)
Correcting Errors in Writing a Medical Record - answer✔✔"White out" should not be used on a
medical record.
Proper method of correcting a mistake is to put a line through the error, write "error" above the
mistake, date and initial it.
Signing your notes in Writing a Medical Record - answer✔✔You should sign every entry that
you make into the medical record
Referring to Yourself - answer✔✔Notes discuss the patient and not the therapist.
All references should be in third person (AT, PT, etc.)
Blank or empty Lines - answer✔✔Lines should not be left between one entry and another, nor
should empty lines be left within a single entry.
Empty lines are area in which another person could falsify information already charted.
Writing orders in charts - answer✔✔When a physician gives an order it maybe your
responsibility for writing it in the chart.
Date/Time/Order
Stating the Problem - answer✔✔The problem part of the note can be stated as the patient's chief
complaint, the dx, or loss of function.
