CRA Progress Notes & SOAP Format 2

Question 1

In a SOAP note, where would a recreation aide document that a resident refused to participate in bingo due to fatigue?

Accepted Answer

Subjective

Answer

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?

Accepted Answer

Objective

Answer

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:

Accepted Answer

Complains of

Answer

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:

Accepted Answer

Subjective data

Answer

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?

Accepted Answer

Resident smiled three times and clapped twice during music therapy

Answer

Counting specific behaviors (smiled 3 times, clapped twice) provides measurable, objective documentation.

(CRA) Certified Recreation Aide Practice Test