HCB 102 SOAP Practice Questions and Correct Answers
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Course
HCB 102
Institution
HCB 102
Subjective symptoms verbally given to the HM by the patient or by a significant other; include the patient's description of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness
Objective signs the HM can actually see,...
HCB 102 SOAP Practice Questions and
Correct Answers
Subjective ✅symptoms verbally given to the HM by the patient or by a significant
other; include the patient's description of pain or discomfort, the presence of nausea or
dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness
Objective ✅signs the HM can actually see, hear, touch, feel, or smell; include
measurements such as temperature, pulse, respiration, skin color, swelling, and results
of tests
Assessment ✅diagnosis of the patient's condition; this is where you think through the
results of the history and the physical examination; calls for the providers interpretation
and evaluation of the problem, the data, possible implication and prognosis
Plan ✅treatment given; may include laboratory and/or radiological tests ordered,
medications ordered, treatments performed, patient referrals, patient disposition, patient
education, and follow-up guidelines for the patient
History of Present Illness (HPI) ✅contains all the relevant information to the patient's
chief complaint : issues not found in an examination, documented in direct quotes
Past medical history (SUBJ) ✅-contains info that may contribute to the HPI
-list any significant medical diagnosis or disease condition the patient has
-can help determine possible causes of the chief complaint or to rule out other
possibilities
-may also impact treatment decisions
Past surgical history (surghx) (SUBJ) ✅lists any significant surgical procedures that
have been performed
Family history (famhx) (SUBJ) ✅cardiovascular disease, diabetes, hypertension,
cancer or other pertinent Hx of mother, father, siblings, history
Social History (sochx) (SUBJ) ✅use of tobacco, alcohol and/or illegal substances
Objective assessment ✅includes vital signs, general impression, physical examination
(HEENT)
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