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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Home health certification and plan of treatment.This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided.A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.

Choice B is wrong becauseOutcome and Assessment Information Set (OASIS)is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.

OASIS is not used to certify eligibility or plan treatment.

Choice C is wrong becauseHome care flow sheetis a form that HHAs use to document the daily care provided by nurses and home health aides.

A home care flow sheet does not certify eligibility or plan treatment.

Choice D is wrong becauseHome care progress noteis a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.

A home care progress note does not certify eligibility or plan treatment.

A. A summary of all the interventions performed since admission. B. A description of how the nurse feels about the client’s situation. C. A comparison of the client’s condition with other similar cases. D. A statement of facts, changes, trends, and responses to treatment.

Correct Answer is D

Explanation

A statement of facts, changes, trends, and responses to treatment.This is the best way to report a change in a client’s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.

Choice A is wrong because a summary of all the interventions performed since admission is too broad and may not reflect the current situation of the client.

Choice B is wrong because a description of how the nurse feels about the client’s situation is subjective and may not be helpful for the other health care provider.Choice C is wrong because a comparison of the client’s condition with other similar cases is not specific to the individual client and may not account for differences in factors such as age, comorbidities, or preferences.

Normal ranges for vital signs, laboratory values, and other parameters may vary depending on the source and the context, but some common examples are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

• Oxygen saturation: greater than 95%.

• Blood glucose: 4.0 to 7.8 mmol/L (72 to 140 mg/dL).

• Hemoglobin: 13.5 to 17.5 g/dL for males, 12.0 to 15.5 g/dL for females.

• White blood cell count: 4.0 to 11.0 x 10^9/L.

• Platelet count: 150 to 400 x 10^9/L.

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A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

Correct Answer is A

Explanation

A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

Correct Answer is D

Explanation

A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (Select all that apply.).

What is one advantage of using a computerized system for documentation and reporting?

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is using the focus charting method to document care for a client who has diabetes mellitus. Which of the following terms should the nurse use to begin each entry?

A nurse is using SOAP format to document a client’s progress note.

What does SOAP stand for?