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SOAP NOTE Subjective - Lesson Quizzes with Correct Verified Answers
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SOAP NOTE Subjective - Lesson Quizzes with Correct Verified Answers
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SOAP NOTE Subjective - Lesson Quizzes withCorrect Verified Answers
Is the chief complaint one of the eight ELEMENTS of the HPI? - ANSWER No. The elements
describe the chief complaint.
Which HPI structure is best to use for a complex patient with multiple co-morbidities and
a recent work-up? - ANSWER Chronologic Structure
The "chronologic" structure is best for complex stories:
Patients with multiple co-morbidities; Patients who have had a significant workup in the
past; Established patients here for follow-up of a chronic illness
The multiple complaint formula is used primarily in which specialty? - ANSWER Primary Care
Clinic or Internal Medicine OP Practice
T/F: The first step in every HPI structure begins with the age and sex of the patient. - ANSWER
True
Which HPI structure is best for a patient with a single complaint? - ANSWER Single Complaint
Formula
T/F: Abbreviations are permitted in the HPI as long as they are approved medical abbreviations.
- ANSWER True
T/F: It is okay for scribes to misspell words because doctors do it all the time. - ANSWER False
, How would you document the onset of symptoms that began on Wednesday? - ANSWER You
would count back the days to Wednesday and write a specific number of days.
If the patient says, "It hurts when I touch it," what would you write in the HPI? - ANSWER The
patient complains of sensitivity to touch in the specific location.
Give the definition of the word exacerbate. - ANSWER Make worse
T/F: ROS stands for Review of Symptoms. - ANSWER False. ROS stands for Review of Systems.
Can the ROS contradict information in the HPI? Why or why not? - ANSWER Information in the
ROS cannot contradict information in the HPI because both are subjective.
T/F: The ROS does not contain the chief complaint and its associated symptoms because
they are already listed in the HPI. - ANSWER False
Name three symptoms that would be listed under the neurological section of the ROS. -
ANSWER Headaches, Syncope, Seizure, Numbness, Focal weakness
Why must you be ready to type or click quickly during a physician-led ROS? - ANSWER Doctors
who perform this type of ROS speak very quickly.
T/F: "I don't have any responsibility with regards to the ROS because the nurses complete
the ROS at my facility." - ANSWER False. You have to make sure that the HPI and ROS do not
contradict one another.
How will you document the ROS in most EMRs?
a. Full sentences
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