A nurse is using SOAP format to document a client’s progress note.
What does SOAP stand for?
Subjective, Objective, Assessment, Plan.
Situation, Observation, Action, Problem.
Summary, Outcome, Analysis, Process.
Source, Opinion, Accuracy, Purpose.
The Correct Answer is A
Subjective, Objective, Assessment, Plan. This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong because Situation, Observation, Action, Problem is not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong because Summary, Outcome, Analysis, Process is not a documentation method, but a framework for writing reflective essays.
Choice D is wrong because Source, Opinion, Accuracy, Purpose is not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.
Choice A is wrong because a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.Choice C is wrong because a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.Choice D is wrong because a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.
Normal ranges for COPD are: FEV1/FVC ratio < 0.7; FEV1 < 80% predicted; FVC normal or reduced; TLC > 80% predicted; RV > 120% predicted; DLCO < 80% predicted.
Correct Answer is A
Explanation
Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.
Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.
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