Question 1

Why is it important to provide documentation related to the patient's increase in strength?
A) It provides a means of showing treatment effectiveness.
B) It helps the patient decide if therapy is helping.
C) It provides the family with a measurement of how they think the patient is progressing.
D) It helps the physician determine how many more treatment sessions are necessary.

Accepted Answer

By documenting an increase in strength, the therapist can decide if treatment being used to increase strength is effective.

Question 2

Why is it important to describe the patient's level of function in the objective section of the SOAP note?
A) It helps determine how much pain the patient is experiencing.
B) It will help determine what services the patient needs.
C) This information is not necessary in this section of the SOAP note.
D) It will help the therapist determine if the level of function improves.

Accepted Answer

Information that provides the therapist with the patient's level of function is important to help determine if the treatment is successful and will improve function.

Question 3

What kind of data does the objective section contain?
A) Data that summarizes the patient's history and assessment
B) Data that includes what is going to happen
C) Data that contains the patient's medical history
D) Data that can be reproduced or confirmed

Accepted Answer

The objective section must include information that is reproducible and measurable so that other professionals can duplicate the treatment session.

Question 4

In proper documentation, it is important for the PTA to demonstrate that skilled intervention is necessary and that the activity cannot be performed by anyone other than a professional.Identify the statement that fits this parameter.
A) The patient performed an (I) transfer from BS to w/c with SBA x2 with appropriate vc regarding proper body mechanics.
B) The patient reported that he was able to get out of bed today without any help.
C) The patient needs to return to the physician for another update and script for continued services.
D) The patient performed quad sets 10x, 3 sets today compared to 10x,1 set last session.

Accepted Answer

For the statement to be included in the objective section, it must include information about activity that can be performed with a therapist guiding the patient. The only activity that could not be performed by the patient or someone else is in the statement that gives specific parameters related to the activity. The other examples would not be objective statements.

Question 5

Identify the statement below that is NOT an appropriate objective response.
A) The patient performed 10 reps, 3 sets of (B) elbow flexion.
B) The patient ambulated (I), 20 ft. using FWW, SBA 1x.
C) The patient performed (I), AROM in shoulder ext., prone, 10x, 1 set.
D) The patient transferred (I), from EOB to w/c using stand-pivot transfer x 2.

Accepted Answer

Information included in the objective section should have information on the results of tests and measurements, a description of the patient's function, a description of the intervention provided, the PTA's objective observations of the patient, and the number of treatment sessions provided. All of the statements meet these criteria with the exception of the first answer because it does not give the patient's position, what type of ROM was done, and whether the patient completed the activity with or without assistance.

Question 6

Identify the correct objective statement from the list below.
A) Patient demonstrated an antalgic gait pattern while walking into the tx session.
B) Patient demonstrated frequent wt. shifts while sitting 15 min prior to tx.
C) Patient demonstrated the HEP using McKenzie exercises patterns.
D) Patient walks with a shuffling gait pattern with (R) hip, knee, and ankle in flexion.

Accepted Answer

Objective statements must be measurable and reproducible. The statement regarding weight shifting in sitting during a 15-minute period is the only statement that meets these criteria.

Question 7

Even though SOAP note documentation provides an easy method to organize patient information, there are some problems that occur with its use.Identify a common complaint expressed when using a SOAP note format.
A) It focuses on the patient's impairments.
B) It does not record the patient's progress.
C) It does not delineate the plan of care.
D) It does not address goals and outcomes.

Accepted Answer

SOAP note documentation is often criticized because it tends to focus on the patient's impairments and not his or her medical condition, functional level, or outcomes.

Question 8

How many general topics should the objective section contain when used in a progress note?
A) 4
B) 5
C) 6
D) 7

Accepted Answer

There are six general topics used in the objective data in the progress notes, including information on the results of tests and measurements, a description of the patient's function, a description of the intervention provided, the PTA's objective observations of the patient, the number of treatment sessions provided, and any patient education that was included in the treatment session.

Question 9

Identify the statement below that would be included in the objective section of the SOAP note?
A) The patient stated his pain level was a 5/10 following the treatment session.
B) The patient reported that he can use his walker to get to his car now.
C) The patient was able to perform AAROM to (R) shoulder, flex. 0º to 180º, 10 reps, 3 sets.
D) The patient plans on seeing his doctor next week for a follow-up visit.

Accepted Answer

For a statement to be included in the objective section, it must include information on the results of tests and measurement, a description of the patient's function, a description of the intervention provided, the PTA's objective observations of the patient, and the number of treatment sessions provided.

Question 10

What information should be included in the objective 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 provided in the objective section should include anything that is easily reproducible and demonstrable.

Question 11

Identify the parameters that would be included in the objective section of the SOAP note.
A) Vital signs, measurements, plan of treatment
B) Blood pressure, ROM, recommendation for change in plan of care
C) Oxygen saturation level, wound size, position of the patient
D) Referral to another discipline, strength measurements, stride length

Accepted Answer

The objective section must include information related to the patient's treatment that is reproducible and measurable. Oxygen saturation, wound size, and position of the patient meet all of these guidelines. Plan of treatment, recommendations for change in the plan of care, and referral to another discipline, do not.

Question 12

In the objective section of the SOAP note, what is required to meet the criteria for information given in this section?
A) The therapist needs to paint a picture of the treatment session in order to reproduce what occurred.
B) The therapist must be able to determine what the patient's outcomes will be for the plan of care.
C) The therapist must be able to provide the past medical history to determine the plan of action.
D) The therapist must describe a plan of care that includes the patient's ability to function in the gym.

Accepted Answer

The specific goal of the objective section of the SOAP note is to "paint a picture" of the treatment session by writing a description of the treatment provided so any other therapist can duplicate the treatment session based on the information given in the note.

Question 13

Why is documenting the patient's record of attendance important in the treatment program?
A) It ensures that the patient will continue to attend therapy sessions.
B) It forces the patient to arrive on time for all of the treatment sessions.
C) It reflects the patient's compliance with the treatment program.
D) It makes the patient feel guilty when a treatment session is missed.

Accepted Answer

It is important, from a reimbursement standpoint, to be able to determine whether a patient is compliant with the prescribed therapy sessions and that the patient has attended the prescribed number of treatment sessions. By documenting attendance, everyone is assured that the patient is attending the treatment sessions as outlined in the physician's prescription and the plan of care.

Question 14

What type of objective information should be included in the initial evaluation?
A) ROM and strength assessment
B) Pain level during activity
C) Completion of short-term goals
D) Ability to take a shower

Accepted Answer

The findings that are reported regarding the patient's initial measurements in ROM and strength are appropriate for the objective section in the initial evaluation. The pain level, completion of short-term goals, and the ability to take a shower are not included in this section.

Question 15

Identify the correct test/measurement listed below that would be included in the objective section of the SOAP note?
A) Goals or outcomes review
B) Rating of pain
C) Referral to OT services
D) Girth or circumference measurements

Accepted Answer

Girth or circumference measurements are included in objective type statements because they delineate specific assessments related to the patient's treatment session.

Question 16

General objective data provides specific information to the reader and helps paint a picture of the treatment session.Identify the data that would be incorrect for the PTA to use in the objective section.
A) A description of the intervention provided
B) A summary of the subjective section
C) A record of the number of treatment sessions provided
D) The results of tests and measurement

Accepted Answer

Objective data meets five general criteria, including the description of the intervention, recording the number of treatment sessions provided, the results of tests and measurements, a description of the patient's function, and the therapist's objective observation of the patient.

Question 17

Why is it important to provide sufficient information when writing objective information?
A) So the treating therapist can remember what he or she did during the last session
B) So another therapist can reproduce the treatment session if the first therapist is absent
C) So the therapist can answer all of the patient's questions about each treatment session
D) So the patient can tell his or her family what the treatment session included

Accepted Answer

It is important for all information included in the objective section to be reproducible for another therapist in the absence of the patient's original therapist. Objective statements must paint a picture of the session so any other therapist can easily duplicate the treatment session if he or she needs to work with the patient.

Question 18

In SOAP note documentation, what description is the PT's documentation goal in the objective section?
A) Patient's level of pain
B) Patient's function
C) Treatment protocol
D) Treatment plan

Accepted Answer

The PT and the PTA should always be aware of the patient's level of function as it relates to the plan of care and always include this in the objective section. By identifying the patient's functional level and his or her ability to demonstrate improvement in this level, the therapist can ensure that skilled intervention is being provided.

Question 19

Which individual is responsible for determining when the patient should be discharged from therapy services?
A) Physician
B) PT
C) PTA
D) MSW

Accepted Answer

Because the PT initiates the plan of care following the evaluation, the PT is responsible for determining when the patient is ready to be discharged because he or she has met the goals or has reached a plateau in his or her progress and should be discharged from therapy services. The PTA can make a recommendation to the PT that the patient has met his or her goals and may be ready for discharge.

Question 20

Who is responsible for changing the goals that fall outside the plan of care during the treatment session?
A) PT and PTA
B) PT
C) Patient
D) PT and patient

Accepted Answer

The PT is responsible for changing the goals if the change will be outside of the current plan of care. However, if the change in goals remains within the current plan of care, the PTA may change them.

Quiz 8: What Is Objective Data and Why Is It Important?

Why is it important to provide documentation related to the patient's increase in strength?

Why is it important to describe the patient's level of function in the objective section of the SOAP note?

What kind of data does the objective section contain?

In proper documentation, it is important for the PTA to demonstrate that skilled intervention is necessary and that the activity cannot be performed by anyone other than a professional.Identify the statement that fits this parameter.

Identify the statement below that is NOT an appropriate objective response.

Identify the correct objective statement from the list below.

Even though SOAP note documentation provides an easy method to organize patient information, there are some problems that occur with its use.Identify a common complaint expressed when using a SOAP note format.

How many general topics should the objective section contain when used in a progress note?

Identify the statement below that would be included in the objective section of the SOAP note?

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

Identify the parameters that would be included in the objective section of the SOAP note.

In the objective section of the SOAP note, what is required to meet the criteria for information given in this section?

Why is documenting the patient's record of attendance important in the treatment program?

What type of objective information should be included in the initial evaluation?

Identify the correct test/measurement listed below that would be included in the objective section of the SOAP note?

General objective data provides specific information to the reader and helps paint a picture of the treatment session.Identify the data that would be incorrect for the PTA to use in the objective section.

Why is it important to provide sufficient information when writing objective information?

In SOAP note documentation, what description is the PT's documentation goal in the objective section?

Which individual is responsible for determining when the patient should be discharged from therapy services?

Who is responsible for changing the goals that fall outside the plan of care during the treatment session?