Daily SOAP Note Audit Remediation Quiz

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* 1. First Name

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* 2. Last Name

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* 3. All of the following are functions of a SOAP note except:

A SOAP note provides a record of the patient encounter and treatment applied to patient.

A SOAP note provides evidence of medical necessity for treatment to a third party payer.

A SOAP note provides a standardized way to share information about a patient’s condition and progress with other healthcare providers.

A SOAP note provides protection from legal judgment because SOAP notes are not considered admissible evidence.

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* 4. Which of the following is not a required part of a complete subjective note?

The patient’s opinion of their response to care thus far.

A review of chief complaint since LPV.

ROM for area of chief complaint.

A statement detailing functional deficits such as ADL limitations or ROM restrictions.

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* 5. Which of the following examples completely satisfies PART requirements?

L4 tenderness on palpation; hypertonic lumbar paraspinals bilaterally.

Csp, Tsp, and Lsp AROM in all directions WNL without pain.

Right short leg, lengthens in Position 2.

C3 LRR; tenderness on palpation of right articular pillar at C3.

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* 6. A patient in your office consistently misses appointments and is failing to meet the goals you set in his care plan. In your professional opinion, his slow progress is because he has not followed your recommendations. In which part of a SOAP note would you document this?

Objective

Assessment

It is not necessary to document this.

Plan

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* 7. Which of the following is true of PART requirements?

At least one of the documented PART findings must be from “A” or “R”.

Only Medicare patients require two PART findings.

Diagnostic imaging can not be used to satisfy PART findings.

It is not necessary to evaluate a maintenance patient for PART findings.

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* 8. Which of the following claims might be eligible for reimbursement by a third party?

A claim submitted for a patient with a single complaint of lower back pain billed for a spinal adjustment and a shoulder adjustment.

A claim submitted for a patient with chief complaint of neck pain and objective findings of anterior head carriage and decreased segmental ROM at C2.

A claim submitted for a patient who presents with pain on each visit but no longer reports any functional improvement.

A claim submitted for an asymptomatic patient presenting for wellness care.

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* 9. Which of the following is not a required part of a complete assessment note?

An evaluation of the patient’s pain using a standardized rating scale.

Supporting evidence from both subjective and objective note.

A statement detailing how the chief complaint has responded to care.

A statement detailing functional deficits such as ADL limitations or ROM restrictions.

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* 10. A patient in your office complains that her skin feels irritated following treatment with electrical stimulation. When you look at her skin, there appears to be a burn. In which part of a SOAP note would you document this?

It is not necessary to document this.

Assessment

Plan

Objective

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* 11. Which of the following is not a required part of a complete plan note?

Services rendered and response to treatment.

Supporting evidence from subjective and objective note.

Diagnosis codes supporting chief complaint.

Recommended frequency and duration of treatments.

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* 12. A patient in your office has been seen multiple times for an acute condition and has always had an antalgic lean forward and complained of being unable to stand up straight. When he arrived today, you observed that he was able to stand completely upright. In which part of a SOAP note would you document this?

Objective

It is not necessary to document this.

Plan

Subjective