PMHNP SOAP Note questionnaire

Consulting the Answer Key, please answer the followingquestions:

1.      What does the S stand for in the SOAPnote format?

2.     Whatinformation is contained in the S section?

3.     Whatdoes the O stand for in the SOAP note format?

4.     What information is contained in the Osection?

5.     Whatdoes the A stand for in the SOAP note format?

6.     Whatinformation is contained in the A section?

7.     Whatdoes the P stand for in the SOAP note format?

8.     Whatinformation is contained in the P section?

9.     Whatis the purpose of the PMHNP Soap Note?

10.  Whichsection contains information that can be observed or measured?

11.  Whichsection contains the differential diagnoses?

12.  Whichsection contains the Mental Status Exam (MSE)?

Answerkey:

These terms may be applicable to more than one question.

     Subjective

     Guides clinical reasoning, diagnosis, andtreatment decisions; facilitates communication among providers, tracks progress

     Objective

     Chief complaint, demographic information, HPI,PMH, Social History

     Assessment

     Plan

     VS, ROS, MSE, labs, screening assessments,facts

     Diagnosis and differential diagnoses, DSM-5criteria, and potential treatment options

     Specific instructions for medications anddosing, lab work ordered, referrals, therapy recommendations, follow up