CRA Progress Notes & SOAP Format 3 — Questions and Answers
Question 1: An error is made in a paper progress note. The correct procedure is to:
- Use correction fluid (white-out) to cover the mistake
- Completely scribble out the error
- Draw a single line through the error, initial, and date it (Correct answer)
- Remove and rewrite the entire note
Correct answer: Draw a single line through the error, initial, and date it
Correct documentation errors by drawing one line through the mistake, then initialing and dating it to maintain a clear record.
Question 2: Which of the following is NOT appropriate to include in a recreation therapy progress note?
- Resident's response to activity
- Aide's personal opinion of the resident's personality (Correct answer)
- Goals addressed during the session
- Level of assistance required
Correct answer: Aide's personal opinion of the resident's personality
Personal opinions about a resident's personality are inappropriate and unprofessional in clinical documentation.
Question 3: Documentation must be completed:
- At the end of the week
- As soon as possible after the intervention (Correct answer)
- Only when a significant event occurs
- When the supervisor requests it
Correct answer: As soon as possible after the intervention
Timely documentation immediately after an intervention ensures accuracy and reduces the risk of forgotten details.
Question 4: In SOAP format, the 'P' section for a resident with limited mobility might read:
- Resident states knees hurt during walking activities
- Resident required min assist to walk 20 feet
- Resident's pain limits full participation in exercise groups
- Continue modified chair exercises 3x/week; consult PT re: ambulation goals (Correct answer)
Correct answer: Continue modified chair exercises 3x/week; consult PT re: ambulation goals
The Plan section outlines future interventions and referrals, not current observations or assessments.
Question 5: Why is it important to avoid vague terms like 'good' or 'bad' in progress notes?
- They are difficult to spell
- They do not provide measurable or meaningful clinical information (Correct answer)
- They are too positive for professional documentation
- They may offend the resident
Correct answer: They do not provide measurable or meaningful clinical information
Vague terms lack specificity and do not communicate clinically useful information about resident status or progress.
Question 6: A recreation aide documents that a resident 'was non-compliant.' This phrasing is problematic because:
- It uses too many letters
- It is judgmental and doesn't describe actual behavior (Correct answer)
- It belongs in the plan section instead
- It should only be written by a therapist
Correct answer: It is judgmental and doesn't describe actual behavior
Labeling a resident 'non-compliant' is judgmental; instead, document the specific behavior such as 'resident declined to participate when offered.'
Question 7: Which documentation practice protects the recreation aide legally?
- Documenting only positive outcomes
- Leaving blank spaces in notes to add detail later
- Recording accurate, factual, and timely notes (Correct answer)
- Documenting what the nurse told you happened
Correct answer: Recording accurate, factual, and timely notes
Accurate, factual, and timely documentation is the aide's best legal protection and ensures quality care records.
CRA Progress Notes & SOAP Format 3
An error is made in a paper progress note.
The correct procedure is to: