CRA Progress Notes & SOAP Format 2 — Questions and Answers
Question 1: In a SOAP note, where would a recreation aide document that a resident refused to participate in bingo due to fatigue?
- Subjective (Correct answer)
- Objective
- Assessment
- Plan
Correct answer: Subjective
The resident's self-reported reason (fatigue) is subjective information and belongs in the S section.
Question 2: A recreation aide observes that a resident completed a 500-piece puzzle without assistance. This should be recorded in which SOAP section?
- Subjective
- Objective (Correct answer)
- Assessment
- Plan
Correct answer: Objective
Directly observed, measurable behaviors belong in the Objective section of a SOAP note.
Question 3: When documenting in a progress note, using the abbreviation 'c/o' means:
- Complains of (Correct answer)
- Cares of
- Certified observation
- Condition of
Correct answer: Complains of
The abbreviation 'c/o' stands for 'complains of' and is commonly used in clinical documentation.
Question 4: A progress note states a resident 'appeared anxious.' This phrasing is best categorized as:
- Objective data
- Subjective data (Correct answer)
- Assessment
- Plan
Correct answer: Subjective data
Appearance-based inferences like 'appeared anxious' are subjective interpretations unless supported by measurable signs.
Question 5: Which of the following is the BEST example of objective language in a progress note?
- Resident seemed happy
- Resident appeared to enjoy the activity
- Resident smiled three times and clapped twice during music therapy (Correct answer)
- Resident had a good day
Correct answer: Resident smiled three times and clapped twice during music therapy
Counting specific behaviors (smiled 3 times, clapped twice) provides measurable, objective documentation.
Question 6: Which section of a SOAP note would include the recreation aide's interpretation of a resident's declining attendance in group activities?
- Subjective
- Objective
- Assessment (Correct answer)
- Plan
Correct answer: Assessment
The Assessment section contains the aide's or team's analysis and interpretation of the subjective and objective data.
Question 7: A recreation aide plans to increase a resident's social activity participation to three times per week. This belongs in which SOAP section?
- Subjective
- Objective
- Assessment
- Plan (Correct answer)
Correct answer: Plan
The Plan section outlines the intended course of action or intervention going forward.
CRA Progress Notes & SOAP Format 2
In a SOAP note, where would a recreation aide document that a resident refused to participate in bingo due to fatigue?