Question 1

From the statements provided, identify the correct subjective statement.
A) The patient reported that he went bowling last night and met a nice girl.
B) The patient reported that he played chess with his grandmother yesterday and she won.
C) The patient reported that his pain level was 6/10 prior to treatment today.
D) The patient reported that his pain level was 3/10 in his right shoulder prior to treatment today.

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?
A) Information that describes what will happen next
B) Information that provides a summary of subjective and objective information
C) Information that is easily reproducible and demonstrable
D) Information about the patient's past medical history

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.
A) The patient was able to ambulate (I) 20 feet using a front-wheeled walker.
B) The patient will be referred to OT for a hand splint.
C) The patient reported his pain level prior to treatment was a 6/10 on the VRS.
D) The patient will continue to be seen 2x/week.

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.
A) To document a patient's attitude toward therapy
B) To document the patient's dietary habits
C) To document the patient's activities with friends
D) To document the patient's ability to look for a job

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.
A) The patient told me he had cheerios for breakfast.
B) The patient stated that he played poker with his friends last night.
C) The patient reported that he was able to walk 100? to the mailbox this morning without his walker.
D) The patient reported that he had an argument with his mother-in-law again.

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?
A) Personal history
B) Assessment information
C) Patient's goals and outcomes
D) Subjective information

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?
A) The patient can point to a symbol that identifies his or her pain level.
B) The patient does not have to report his or her pain level if it cannot be communicated verbally.
C) A family member or the caregiver can provide the pain level for the patient.
D) The patient can use Morse Code to tap out his or her pain level.

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?
A) Analytic listening
B) Directed listening
C) Exploratory listening
D) Appreciative listening

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.
A) The patient reports that his wife is always nagging him.
B) The patient states that he would like to be able to go drinking with his buddies, again.
C) The patient stated that she wants to be able to walk up and down the two steps into her house.
D) The patient is eating all foods by mouth.

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?
A) Patient's level of independence in combing hair
B) Patient's initial pain level
C) Patient's ability to ambulate independently on even ground
D) Patient's ability to take a shower without assistance

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?
A) Attentive listening
B) Appreciative listening
C) Exploratory listening
D) Courteous listening

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?
A) Passive
B) Courteous
C) Exploratory
D) Appreciative

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?
A) It can help patients determine whether the pain will get better.
B) It provides a measurement to help determine if treatment is helping or hindering the patient's progress.
C) It provides the therapist with a measure of how the patient is progressing in the plan of care.
D) It helps the physician determine if the patient is getting worse and the diagnosis needs to be reevaluated.

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?
A) Attentive listening
B) Exploratory listening
C) Passive listening
D) Courteous listening

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?
A) Body Drawing
B) PLE
C) Pain Profile
D) VRS

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).
A) Attentive
B) Passive
C) Analytic
D) Exploratory

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.
A) Can be recorded by anyone
B) Does not need to be recorded in the daily progress note
C) Must be relevant
D) Must be a direct quote

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.
A) "My left hip hurts because I fell last night."
B) "I drank too much last night and have a hangover."
C) "I took my driver's license exam this morning."
D) "My brother is coming to visit this week."

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.
A) The patient stated that the pain in his (R) hip was 8 following the last treatment session.
B) The patient reported that the pain in her (L) shoulder was 7/10 prior to treatment today.
C) The patient stated that he had no pain in his leg today.
D) The patient reported that his wife was a pain in the neck.

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.
A) The patient reported that he watched the Super Bowl yesterday.
B) The patient stated that he was able to sit for 15 minutes to watch TV last night without increasing pain.
C) The patient reported his pain was 7/10 today, much worse than prior to the last session.
D) The patient reported he was able to walk without his FWW today.

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.