12. Kait Simmons is a nurse at Memorial Hospital. She has just entered
this note on her patient, Alex Philips, by typing the sentences: "The patient
is resting comfortably; he notes that his pain is 7 on a scale of 1-10. He
voices no other complaints." This is an example of
data.
A. structured
B. unstructured
C. quantitative
D. qualitative
13. In a hospital setting, the care provider takes the patient's history,
details the reason the patient is being admitted, and performs a physical
exam. The report of this information is known as the:
A. initial progress note
B. discharge summary
C. history and physical
D. SOAP note
14. The results of a patient's rapid strep test would be found in what area
of a SOAP note?
A. subjective
B. objective
C. assessment
D. plan
15. The SOAP documentation format is most commonly used in which
healthcare setting?
A. hospital inpatient
B. physician's office
C. hospital emergency department
D. outpatient diagnostic department
16. Dr. Schultz has just examined Natalia Shrier who had come to see him
because she has been having increasing problems with gastroesophageal
reflux. Dr. Schultz has instructed Natalia to avoid hot, spicy foods, to
avoid eating within three hours of going to bed, to raise the head of her
bed, and has given her an order to have an Upper GI x-ray. Dr. Schultz's
instructions are part of which element in a SOAP note?
A. Subjective
B. Objective
C. Assessment
D. Plan
17. In a hospital setting, what document is the equivalent of the
assessment and plan that is collected as part of a SOAP note in an
outpatient record?
A. history and physical
B. discharge summary
C. progress note
D. procedure note
(