SOAP Note 3 CP1 & CP2 NURS 5337 12YearOld Female Clinical
CheckOff Template | Latest Update 2026/2027 | 200 Practice
Questions with Verified Answers & Rationales | A+ Graded
SOAP Note Structure & Documentation (Questions 1–30)
1. What does the acronym SOAP stand for in clinical documentation?
A) Symptoms, Observations, Assessment, Prescription
B) Subjective, Objective, Assessment, Plan
C) Summary, Objective, Analysis, Prescription
D) Subjective, Omission, Analysis, Plan
Answer: B SOAP is the standard format for clinical progress notes: Subjective (patientreported
information), Objective (measurable data), Assessment (diagnoses and clinical reasoning), and Plan
(treatment and followup).
2. According to UTA NURS 5337 requirements, which of the following elements must be included in the
Subjective section of a CP1 SOAP note?
A) Vital signs and physical exam findings
B) Differential diagnoses with ICD10 codes
C) Chief complaint, HPI using OLDCARTS, PMH, medications, allergies, and ROS
D) Diagnostic tests ordered and followup plan
Answer: C The Subjective section includes the chief complaint (direct quote), HPI using OLDCARTS, past
medical history, current medications, allergies, and review of systems. Vital signs and physical exam
belong in Objective; differentials belong in Assessment; tests and followup belong in Plan.
,3. True or False: In the UTA SOAP Note template, the HPI must be written in paragraph form using
complete sentences, not bullet points.
A) True
B) False
Answer: A The HPI must be written in paragraph form using complete sentences for proper clinical
documentation.
4. The OLDCARTS mnemonic is used to document which part of the SOAP note?
A) Objective
B) Assessment
C) History of Presenting Illness (HPI)
D) Plan
Answer: C OLDCARTS (Onset, Location, Duration, Character, Alleviating/Aggravating, Radiation, Timing,
Severity) is used to structure the History of Presenting Illness in the Subjective section.
5. Which of the following is an example of subjective data?
A) Blood pressure 120/80 mmHg
B) Heart rate 72 bpm
C) Patient reports "I have a headache that started this morning"
D) Lung sounds clear to auscultation
Answer: C Subjective data includes information reported by the patient, such as symptoms, feelings,
and perceptions. Objective data includes measurable findings like vital signs and physical exam results.
,6. Which of the following is an example of objective data?
A) Patient states "I feel dizzy when I stand up"
B) Patient reports abdominal pain rated 6/10
C) Temperature 101.2°F (38.4°C)
D) Patient complains of nausea
Answer: C Objective data includes measurable and observable findings obtained through physical
examination, vital signs, and diagnostic tests. Temperature is a measurable objective finding.
7. In the SOAP note format, the Assessment section should include:
A) Only the primary diagnosis
B) Differential diagnoses, problem list, and clinical reasoning
C) Only the treatment plan
D) Patient's vital signs
Answer: B The Assessment section includes differential diagnoses, problem list prioritization, and
clinical reasoning that supports the diagnoses.
8. The Plan section of a SOAP note should include:
A) Only medication prescriptions
B) Diagnostic testing, treatment, patient education, and followup
C) Only followup appointments
, D) Physical exam findings
Answer: B The Plan section includes diagnostic testing selection, evidencebased treatment planning,
pharmacologic and nonpharmacologic interventions, patient education, and followup planning.
9. Which of the following is NOT a component of the Subjective section?
A) Chief complaint
B) History of Presenting Illness
C) Physical examination findings
D) Review of Systems
Answer: C Physical examination findings belong in the Objective section, not the Subjective section.
10. The "C" in OLDCARTS stands for:
A) Cause
B) Character
C) Condition
D) Complications
Answer: B In the OLDCARTS mnemonic, C stands for Character (what the symptom feels like).
11. The "A" in OLDCARTS stands for:
A) Assessment
CheckOff Template | Latest Update 2026/2027 | 200 Practice
Questions with Verified Answers & Rationales | A+ Graded
SOAP Note Structure & Documentation (Questions 1–30)
1. What does the acronym SOAP stand for in clinical documentation?
A) Symptoms, Observations, Assessment, Prescription
B) Subjective, Objective, Assessment, Plan
C) Summary, Objective, Analysis, Prescription
D) Subjective, Omission, Analysis, Plan
Answer: B SOAP is the standard format for clinical progress notes: Subjective (patientreported
information), Objective (measurable data), Assessment (diagnoses and clinical reasoning), and Plan
(treatment and followup).
2. According to UTA NURS 5337 requirements, which of the following elements must be included in the
Subjective section of a CP1 SOAP note?
A) Vital signs and physical exam findings
B) Differential diagnoses with ICD10 codes
C) Chief complaint, HPI using OLDCARTS, PMH, medications, allergies, and ROS
D) Diagnostic tests ordered and followup plan
Answer: C The Subjective section includes the chief complaint (direct quote), HPI using OLDCARTS, past
medical history, current medications, allergies, and review of systems. Vital signs and physical exam
belong in Objective; differentials belong in Assessment; tests and followup belong in Plan.
,3. True or False: In the UTA SOAP Note template, the HPI must be written in paragraph form using
complete sentences, not bullet points.
A) True
B) False
Answer: A The HPI must be written in paragraph form using complete sentences for proper clinical
documentation.
4. The OLDCARTS mnemonic is used to document which part of the SOAP note?
A) Objective
B) Assessment
C) History of Presenting Illness (HPI)
D) Plan
Answer: C OLDCARTS (Onset, Location, Duration, Character, Alleviating/Aggravating, Radiation, Timing,
Severity) is used to structure the History of Presenting Illness in the Subjective section.
5. Which of the following is an example of subjective data?
A) Blood pressure 120/80 mmHg
B) Heart rate 72 bpm
C) Patient reports "I have a headache that started this morning"
D) Lung sounds clear to auscultation
Answer: C Subjective data includes information reported by the patient, such as symptoms, feelings,
and perceptions. Objective data includes measurable findings like vital signs and physical exam results.
,6. Which of the following is an example of objective data?
A) Patient states "I feel dizzy when I stand up"
B) Patient reports abdominal pain rated 6/10
C) Temperature 101.2°F (38.4°C)
D) Patient complains of nausea
Answer: C Objective data includes measurable and observable findings obtained through physical
examination, vital signs, and diagnostic tests. Temperature is a measurable objective finding.
7. In the SOAP note format, the Assessment section should include:
A) Only the primary diagnosis
B) Differential diagnoses, problem list, and clinical reasoning
C) Only the treatment plan
D) Patient's vital signs
Answer: B The Assessment section includes differential diagnoses, problem list prioritization, and
clinical reasoning that supports the diagnoses.
8. The Plan section of a SOAP note should include:
A) Only medication prescriptions
B) Diagnostic testing, treatment, patient education, and followup
C) Only followup appointments
, D) Physical exam findings
Answer: B The Plan section includes diagnostic testing selection, evidencebased treatment planning,
pharmacologic and nonpharmacologic interventions, patient education, and followup planning.
9. Which of the following is NOT a component of the Subjective section?
A) Chief complaint
B) History of Presenting Illness
C) Physical examination findings
D) Review of Systems
Answer: C Physical examination findings belong in the Objective section, not the Subjective section.
10. The "C" in OLDCARTS stands for:
A) Cause
B) Character
C) Condition
D) Complications
Answer: B In the OLDCARTS mnemonic, C stands for Character (what the symptom feels like).
11. The "A" in OLDCARTS stands for:
A) Assessment
