SOAP MID 3

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Author:
elementsninja
ID:
299761
Filename:
SOAP MID 3
Updated:
2015-04-02 14:21:15
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SOAP MID
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SOAP MID 3
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SOAP MID 3
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  1. Left neglect interferes with ability to perform basic ADLs.
    ASSESSMENT
  2. Patient expressed doubts about ever getting better and then began to cry.
    SUBJECTIVE
  3. Mrs. Jones reports that she had no pain in her hip last night or this morning
    SUBJECTIVE
  4. Specific department proper names are
    CAPITALIZED
  5. It is essential that you do not disclose or give out any health records or client information without fully understanding the law and knowing your facility's policies and procedures.
    TRUE
  6. Do not make up your own abbreviations, and do not use any abbreviation that is not on your facility's approved list.
    TRUE
  7. Peter Piper demonstrates improved activity tolerance, as evidenced by standing at the kitchen counter 3 minutes longer than yesterday before requiring rest during meal preparation activity.
    ASSESSMENT
  8. “I don’t need therapy.”
    SUBJECTIVE
  9. The nurse reports that Mrs. Smith has been in her room crying all morning.
    SUBJECTIVE
  10. MMT
    manual muscle test
  11. Mrs. Jones demonstrates readiness to progress to standing with SBA while showering.
    ASSESSMENT
  12. Mrs Jones will perform standing tolerance exercises while cooking breakfast in the OT Clinic next session
    PLAN
  13. Veteran would benefit from further instruction to incorporate total hip precautions into lower body dressing, bathing and toileting
    ASSESSMENT
  14. Child stated, "This is hard!" during a bilateral coordination exercise requiring UE strength and stability.
    SUBJECTIVE
  15. Continue OT one hour daily sessions for two weeks to Improve motor planning skills for dressing.  By the end of the next session, veteran will demonstrate the ability to identify front and back of shirt with one verbal cue.
    PLAN
  16. Use of correction fluid or correction tape in a medical record is considered an illegal alteration of the record.
    TRUE
  17. "It's easier for me to get dressed now."
    • The following is a subjective statement that might be included in a SOAP note:
  18. The OTA asked the patient to _____________ the scissors down on the table.
    LAY
  19. It is understood that the subjective statement in a SOAP note comes from the individual receiving the therapy unless otherwise stated
    TRUE
  20. The following is a subjective statement that might be included in a SOAP note:Resident needed max assist x 2 to transfer from w/c to bed.
    FALSE
  21. The client refused to _____________ the doctor's diagnosis.
    Fill in the blank:
    The client refused to _____________ the doctor's diagnosis.
    ACCEPT
  22. ASSESSMENT=
    DIAGNOSIS

    A medical diagnosis for the purpose of the medical visit on the given date of the note written
  23. SUBJECTIVE=
    the patient's Chief Complaint, or CC
  24. OBJECTIVE=
    information that the healthcare provider observes or measures from the patient's current presentation
  25. PLAN=
  26. The plan is what the health care provider will do to treat the patient's concerns

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