SOAP NOTES QUIZ 1 – Flashcards
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Subjective
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client's perception of the treatment being received, the progress, limitations, needs and problems
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In the subjective note section you only gather information from the client but NOT their significant others.
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False. You gather information from both the client and their significant others
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In this section you can write what the client complains of and use direct quotes when appropriate
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Subjective
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In the subjective section information can easily be measured and verified.
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False. In this section it is not easy to measure or verify this information
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I don't need therapy is an example of what type of SOAP note
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Subjective
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You are to listen carefully and listen intently to elicit pertinent information about the client in the subjective note
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True
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It is important to get clear detail and pinpoints an issue rather than a vague and general comment from the client regarding the subjective note to build a foundation for the rest of the note
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True
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What if the client refuses to speak?
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If the client refusing to speak write this down in the SUBJECTIVE note section
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Where should you include information from the caregiver
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In the subjective section of your notes
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Objective note
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This is information is factual information about your client.
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Objective note
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In this section use terms in your notes that can be seen, smelled, heard, measured or count.
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This section is factual information about your client
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Objective
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The resident participated in a 45 minute session bedside for instruction in compensatory dressing techniques
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Example of an Objective Note
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It is important to SHOW YOUR SKILL in this section. Instead of saying Client participated in a 45 minute session bedside for instruction, ADD.... in compensatory dressing techniques
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Objective.
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It is important to organize these notes either chronologically or by categories
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Objective
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It is important to focus on function in this section, and it must be addressed separately in order to justify skilled occupational therapy
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Objective
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Make certain that occupation is integral to the note
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Objective
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Write from the clients point of view versus mentioning yourself
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Objective
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This is a way to write a Objective statement correctly: OTA instructed the client and family in energy conservation techniques
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FALSE. CLIENT and family were instructed in energy conservation techniques and demonstrated understanding by performing correctly
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This is where you will record all measurable, quantifiable, and observable date obtained during You client's OT session
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Objective Note
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It is important to make skilled observations about what is going on in each occupation, using the framework as a guide
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True, in Objective Note Section
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Social interactions, Judgment & problem solving, Behavior, appearance,work skills
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Objective Note
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What are the four steps when making an Objective note?
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1.Begin with a statement about the Setting & Purpose of the activity & number of minutes *Client seen for___ min. (in what setting) for (purpose of the tx) 2.Follow the Opening Sentence with a summary of what you observed 3.Don't duplicate services Specific FUNCTIONAL activity 4.Make your Note professional, Concise, & specific From: "Veteran had to use a trapeze to sit up" To: "Supine to sit using trapeze"
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Assessment
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Includes the Client's: Functional limits Progress or the lack of progress Expectations of the client's ability to benefit from OT Rehabilitation Potential
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This note section is the health professionals interpretation of the meaning of the events reported in the Objective section.
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Assessment
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What are you noting in the assessment?
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Problems Progress Rehabilitation potential
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In the assessment what is an example of justifying treatment?
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Client's would benefit from visual cues to orient him to time & place
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In this section, the OTA should go sentence by sentence in the data for the "S" and the "O" for each component
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Assessment
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Set a path of treatment. This section allows you to document a way to treat your client.
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Plan
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What are the three things that you should address in the "Plan" note section?
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1.What you plan to do in the client's next OT session. 2.What needs to be addressed in the near future 3.Might be a recommendation for client, family, or caregiver
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Is considered the "heart" of your note
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Assessment section
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Every note does not necessarily reflect progress or rehabilitation potential
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True
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Should reflect specific task components or steps towards meeting the over all goals in the initial intervention (treatment) plan
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Plan
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This type of note is an example of the "Client will (what will client do) (skill) (under what condition) (For what function or occupation gain) (time frame -By when)"
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Plan
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This type of note is an example of the "Client will attend prevocational groups 5 days/wk. in order to increase task behaviors for work ."
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Plan
