NSG 6430 SOAP NOTE SOUTH UNIVERSITY
FINAL TEST 2026 QUESTIONS WITH
CORRECT ANSWERS GRADED A+
◍ What does the term 'malaise' indicate in a health record?.
Answer: A general feeling of discomfort or unease.
◍ Client showed improved right wrist flexion (35°) and extension (25°)
compared to the previous session, improving functional grip strength needed
for typing..
Answer: example of progress in assessment note
◍ What does 'CC' stand for in a health record?.
Answer: Chief Complaint
◍ What does 'mortality' refer to in medical terms?.
Answer: The state of being subject to death; often used in statistics.
◍ What does 'f/u' stand for in medical records?.
Answer: Follow Up
◍ What does the Assessment section of a SOAP note represent?.
Answer: The analysis of subjective and objective information leading to a
diagnosis.
◍ What is the role of a primary care provider (PCP)?.
Answer: To provide general healthcare and manage a patient's overall
health.
◍ What does 'NKDA' stand for?.
Answer: No Known Drug Allergies
◍ What does the objective section of a health record contain?.
Answer: Results of physical exams and observable data.
, ◍ What does 'PMHx' mean?.
Answer: Past Medical History
◍ Client participated in a 30-minute OT session in the outpatient hand clinic to
address R hand strengthening and scar desensitization in preparation for
hand tool use for work in construction..
Answer: example of objective note for preparatory task
◍ What does 'vital signs' include?.
Answer: Temperature, heart rate, and respiratory rate.
◍ What does 'HPI' mean in health records?.
Answer: History of Present Illness
◍ What does the abbreviation 'VS' stand for?.
Answer: Vital Signs
◍ What is the purpose of a consult note?.
Answer: To document a specialist's evaluation and recommendations
regarding a patient's condition.
◍ What is documented in the Objective section of a SOAP note?.
Answer: Data collected by the healthcare provider, including lab tests and
special images.
◍ What does 'labs' refer to in a health record?.
Answer: Laboratory tests and results pertinent to the patient's condition.
◍ What is the significance of the 'family history' section?.
Answer: To identify hereditary conditions that may affect the patient.
◍ What is the difference between acute and chronic conditions?.
Answer: Acute refers to conditions that are severe and sudden in onset,
while chronic refers to long-lasting conditions.
◍ Client requires maximum assistance in w/c to shower chair transfer due to
NWB L leg..
Answer: example of problem in assessment note
FINAL TEST 2026 QUESTIONS WITH
CORRECT ANSWERS GRADED A+
◍ What does the term 'malaise' indicate in a health record?.
Answer: A general feeling of discomfort or unease.
◍ Client showed improved right wrist flexion (35°) and extension (25°)
compared to the previous session, improving functional grip strength needed
for typing..
Answer: example of progress in assessment note
◍ What does 'CC' stand for in a health record?.
Answer: Chief Complaint
◍ What does 'mortality' refer to in medical terms?.
Answer: The state of being subject to death; often used in statistics.
◍ What does 'f/u' stand for in medical records?.
Answer: Follow Up
◍ What does the Assessment section of a SOAP note represent?.
Answer: The analysis of subjective and objective information leading to a
diagnosis.
◍ What is the role of a primary care provider (PCP)?.
Answer: To provide general healthcare and manage a patient's overall
health.
◍ What does 'NKDA' stand for?.
Answer: No Known Drug Allergies
◍ What does the objective section of a health record contain?.
Answer: Results of physical exams and observable data.
, ◍ What does 'PMHx' mean?.
Answer: Past Medical History
◍ Client participated in a 30-minute OT session in the outpatient hand clinic to
address R hand strengthening and scar desensitization in preparation for
hand tool use for work in construction..
Answer: example of objective note for preparatory task
◍ What does 'vital signs' include?.
Answer: Temperature, heart rate, and respiratory rate.
◍ What does 'HPI' mean in health records?.
Answer: History of Present Illness
◍ What does the abbreviation 'VS' stand for?.
Answer: Vital Signs
◍ What is the purpose of a consult note?.
Answer: To document a specialist's evaluation and recommendations
regarding a patient's condition.
◍ What is documented in the Objective section of a SOAP note?.
Answer: Data collected by the healthcare provider, including lab tests and
special images.
◍ What does 'labs' refer to in a health record?.
Answer: Laboratory tests and results pertinent to the patient's condition.
◍ What is the significance of the 'family history' section?.
Answer: To identify hereditary conditions that may affect the patient.
◍ What is the difference between acute and chronic conditions?.
Answer: Acute refers to conditions that are severe and sudden in onset,
while chronic refers to long-lasting conditions.
◍ Client requires maximum assistance in w/c to shower chair transfer due to
NWB L leg..
Answer: example of problem in assessment note
