Question 1

From the statements provided, identify the correct subjective statement.

Accepted Answer

The patient reporting his pain level prior to treatment and identifying where that pain is located is a very relevant statement related to the patient's treatment session. The other three statements are not appropriate or complete for the subjective section.

Question 2

What information should be included in the subjective section of the SOAP note?

Accepted Answer

Information included in the subjective section would include the patient's past medical history, symptoms or complaints that caused the patient to seek medical attention, factors that produced the symptoms, the patient's functional and lifestyle needs, and the patient's goals or expectations for what he or she will gain from the medical care.

Question 3

Subjective information includes specific types of information related to the patient.Choose the statement that would be included in this part of the documentation.

Accepted Answer

The statement that reports the patient's pain level is the only statement that is subjective in nature.

Question 4

Identify the correct statement that indicates when to use a quote from a patient when documenting in the subjective section of the SOAP note.

Accepted Answer

Because subjective information must be directly relevant to the patient and treatment session, only the statement relating to the patient's attitude toward therapy would be appropriate. Although the other examples could be appropriate, unless they directly affected the patient's treatment session, they would not be relevant to the session and would not be included in the subjective section.

Question 5

Identify the correct subjective statement.

Accepted Answer

The only example given that is directly relevant to the patient's treatment is the statement regarding the patient's ability to walk to the mailbox without his walker, which documents a change in the patient's functional level.

Question 6

What is specific to a patient, modified or affected by their personal views, experience, or background, and arises out of or is identified by means of one's perception of one's own states and processes?

Accepted Answer

By definition, subjective information is peculiar to a particular individual; modified or affected by personal views, experience, or background; and arising out of or identified by means of one's perception of one's own states and processes.

Question 7

If the patient cannot verbally communicate with you, how can you determine what his or her pain level might be prior to, during, or following treatment?

Accepted Answer

The patient may use a standardized symbol, such as a face, to demonstrate his or her pain level. That information can then be recorded in the subjective section of the SOAP note.

Question 8

What type of listening technique is used in response to a specific question asked of a patient?

Accepted Answer

A directed listening technique is one that includes listening to a patient's answers when he or she is asked a specific question.

Question 9

When writing subjective information, it is important to use relevant verbs when describing the patient's responses.Choose the statement that uses the words to meet this criterion.

Accepted Answer

The patient who states that she would like to be able to walk in and out of her house is discussing functional outcomes, whereas the other responses are not related to the patient's medical condition or outcomes.

Question 10

What type of subjective information about the patient could be included in an initial evaluation?

Accepted Answer

The patient's pain level would be the appropriate statement to include in the subjective section because it gives the response reported from the patient. Although the other responses are important, they would likely be addressed in the objective or assessment sections of the note.

Question 11

What type of listening technique demonstrates respect for the patient?

Accepted Answer

Courteous listening demonstrates respect for the patient.

Question 12

What type of listening skill provides information simply by overhearing a conversation related to a patient?

Accepted Answer

Passive listening skills provide information gained by overhearing a conversation about a patient.

Question 13

Why is it important to provide documentation related to the patient's level of pain?

Accepted Answer

By continually assessing the patient's pain level, the therapist can determine if the treatment outlined in the plan of care is helping or hindering the patient's progress, it makes it easy for third-party payers to determine if treatment is beneficial, and provides documentation for other disciplines to quickly determine whether the patient is improving with a decrease in the pain level.

Question 14

What type of listening technique may provide information regarding the patient that is not a direct response to a question asked of the patient?

Accepted Answer

Passive listening provides information that one might overhear from a conversation in which one is not directly involved, but may provide insight into the treatment process for that day.

Question 15

We determine a patient's pain level using many tools.What is the most commonly used tool to assess this subjective response?

Accepted Answer

The VRS, or verbal rating scale, is the most commonly used scale to assess a patient's pain level. It rates the patient's pain perception on a scale from 1 to 10 and is related to the patient's own concept of his or her pain, without comparing it to anyone else's pain level.

Question 16

Appropriate listening skills are imperative in patient documentation.Identify the word that defines using listening skills to determine specific types of information (i.e., pain, lifestyle, fears).

Accepted Answer

Analytic listening skills enable the therapist to determine specific types of information about the patient, such as the patient's level of pain, his or her lifestyle and how the pathology impacts it, and fears regarding the loss of function.

Question 17

It is important when discussing subjective information from a patient, caregiver, relative, or others, that the information given meets certain guidelines.Choose the phrase that best describes those guidelines.

Accepted Answer

For information to be included in the subjective section of the SOAP note, it must be relevant to the patient and the treatment process.

Question 18

Identify the correct subjective statement.

Accepted Answer

The only relevant statement that should be included in the subjective section of the SOAP note is the one related to the hip pain because of a fall. The other three statements are not appropriate subjective statements because they are not relevant to the treatment session.

Question 19

Identify the correct written subjective statement regarding the patient's pain level.

Accepted Answer

This is the most relevant statement because it meets the parameters of stating where the pain is located, the time frame or activity related to the pain level, and provides a comparison for the level of pain. The first example only states the pain level is 8, not 8/10; the third example does not state which leg does not have pain; and the last example is not an appropriate subjective statement.

Question 20

Identify the correct subjective statement from the choices listed below.

Accepted Answer

The statement reporting an increase in the patient's ability to sit for a longer time, without pain, is a functional gain and one that should be included in the subjective section. Watching the Super Bowl does not pertain to the patient's functional gain. The patient reporting his pain level is appropriate but no site was given, and the report of walking did not provide the type of surface or how far he was able to walk.

Quiz 7: What Is Subjective Data and Why Is It Important?

From the statements provided, identify the correct subjective statement.

What information should be included in the subjective section of the SOAP note?

Subjective information includes specific types of information related to the patient.Choose the statement that would be included in this part of the documentation.

Identify the correct statement that indicates when to use a quote from a patient when documenting in the subjective section of the SOAP note.

Identify the correct subjective statement.

What is specific to a patient, modified or affected by their personal views, experience, or background, and arises out of or is identified by means of one's perception of one's own states and processes?

If the patient cannot verbally communicate with you, how can you determine what his or her pain level might be prior to, during, or following treatment?

What type of listening technique is used in response to a specific question asked of a patient?

When writing subjective information, it is important to use relevant verbs when describing the patient's responses.Choose the statement that uses the words to meet this criterion.

What type of subjective information about the patient could be included in an initial evaluation?

What type of listening technique demonstrates respect for the patient?

What type of listening skill provides information simply by overhearing a conversation related to a patient?

Why is it important to provide documentation related to the patient's level of pain?

What type of listening technique may provide information regarding the patient that is not a direct response to a question asked of the patient?

We determine a patient's pain level using many tools.What is the most commonly used tool to assess this subjective response?

Appropriate listening skills are imperative in patient documentation.Identify the word that defines using listening skills to determine specific types of information (i.e., pain, lifestyle, fears) .

It is important when discussing subjective information from a patient, caregiver, relative, or others, that the information given meets certain guidelines.Choose the phrase that best describes those guidelines.

Identify the correct subjective statement.

Identify the correct written subjective statement regarding the patient's pain level.

Identify the correct subjective statement from the choices listed below.