Effective clinical documentation is a cornerstone of modern pharmacy practice, allowing pharmacists to clearly articulate their patient assessments and therapeutic plans. The SOAP note—Subjective, Objective, Assessment, and Plan—is a structured, logical format used across healthcare disciplines to document patient encounters and communicate clinical reasoning. As a PharmD student, mastering the art of writing a concise and comprehensive SOAP note is a critical skill developed in courses like the Professional Skills Lab 3 and Patient Care 4. Beyond SOAP notes, pharmacists use other structured communication tools like SBAR to convey urgent information. This quiz will test your knowledge of the components, principles, and applications of these vital documentation and communication methods.
1. In a SOAP note, what does the “S” stand for?
- a. Summary
- b. Systems
- c. Subjective
- d. Situation
Answer: c. Subjective
2. A patient’s statement, “My stomach hurts after I eat,” would be documented in which section of the SOAP note?
- a. S – Subjective
- b. O – Objective
- c. A – Assessment
- d. P – Plan
Answer: a. S – Subjective
3. Which of the following is an example of Objective data?
- a. The patient reports feeling dizzy.
- b. A lab report showing a serum potassium of 2.9 mEq/L.
- c. The patient’s spouse says the patient seems confused.
- d. The patient’s pain score of 8 out of 10.
Answer: b. A lab report showing a serum potassium of 2.9 mEq/L.
4. The pharmacist’s analysis of the patient’s problems and evaluation of their therapy belongs in which section of the SOAP note?
- a. S – Subjective
- b. O – Objective
- c. A – Assessment
- d. P – Plan
Answer: c. A – Assessment
5. Which component of the SBAR communication tool provides relevant context like the patient’s admitting diagnosis and recent events?
- a. Situation
- b. Background
- c. Assessment
- d. Recommendation
Answer: b. Background
6. A recommendation to “Increase lisinopril to 20 mg PO daily for uncontrolled hypertension” would be found in which part of the SOAP note?
- a. Subjective
- b. Objective
- c. Assessment
- d. Plan
Answer: d. Plan
7. A patient’s vital signs (blood pressure, heart rate, temperature) are always considered what type of information?
- a. Subjective
- b. Objective
- c. Assessment
- d. Plan
Answer: b. Objective
8. In the “Assessment” section, a pharmacist identifies that a patient is taking two drugs from the same therapeutic class for the same indication. This is what type of medication therapy problem (MTP)?
- a. Dose too low
- b. Adverse drug reaction
- c. Unnecessary drug therapy / Therapeutic Duplication
- d. Non-adherence
Answer: c. Unnecessary drug therapy / Therapeutic Duplication
9. The “R” in SBAR stands for Recommendation. What does this entail?
- a. A review of the patient’s past medical history.
- b. A restatement of the problem.
- c. A specific, actionable suggestion for what should be done.
- d. A list of all the patient’s current medications.
Answer: c. A specific, actionable suggestion for what should be done.
10. “Hypertension (uncontrolled): Blood pressure remains elevated despite current therapy with HCTZ 25 mg daily.” This statement is a classic example of a pharmacist’s:
- a. Subjective finding
- b. Objective finding
- c. Assessment of a problem
- d. Plan for a problem
Answer: c. Assessment of a problem
11. Which of the following should be included in the “Plan” for each assessed problem?
- a. Specific pharmacologic and non-pharmacologic recommendations.
- b. Goals of therapy.
- c. Parameters for monitoring efficacy and safety.
- d. All of the above.
Answer: d. All of the above.
12. The lab course syllabus for “SOAP Notes and More” is found in which course?
- a. PHA5164L Professional Skills Laboratory 4
- b. PHA5163L Professional Skills Lab 3
- c. PHA5787C Patient Care 5
- d. PHA5104 Sterile Compounding
Answer: b. PHA5163L Professional Skills Lab 3
13. A patient’s self-reported list of allergies belongs in which section?
- a. S – Subjective
- b. O – Objective
- c. A – Assessment
- d. P – Plan
Answer: a. S – Subjective
14. An allergy documented in a previous hospital record and confirmed in the pharmacy system would be considered:
- a. Subjective
- b. Objective
- c. Part of the Plan
- d. Irrelevant
Answer: b. Objective
15. SBAR is most appropriately used for:
- a. Writing a comprehensive daily progress note.
- b. Communicating a specific, urgent patient issue to a provider over the phone.
- c. Counseling a patient at discharge.
- d. Documenting a full medication history.
Answer: b. Communicating a specific, urgent patient issue to a provider over the phone.
16. The “O” in a SOAP note can include:
- a. The patient’s chief complaint.
- b. The patient’s description of their symptoms.
- c. Medication fill history from the pharmacy database.
- d. The patient’s stated goals for therapy.
Answer: c. Medication fill history from the pharmacy database.
17. What is the primary purpose of documenting a pharmacist’s interventions in the EHR?
- a. To meet a daily quota.
- b. To communicate the value and action of the pharmacist to the rest of the healthcare team.
- c. To practice typing skills.
- d. To create a record for billing purposes only.
Answer: b. To communicate the value and action of the pharmacist to the rest of the healthcare team.
18. A statement such as “Patient is non-adherent with their metformin, taking it only 3-4 times per week as reported by the patient” belongs in the:
- a. Objective section.
- b. Subjective section.
- c. Plan section.
- d. Review of Systems.
Answer: b. Subjective section.
19. When writing the “Plan” for a patient, which recommendation is most appropriate and complete?
- a. “Start lisinopril.”
- b. “Start lisinopril 10 mg.”
- c. “Start lisinopril 10 mg PO once daily.”
- d. “Start lisinopril 10 mg PO once daily for hypertension.”
Answer: d. “Start lisinopril 10 mg PO once daily for hypertension.”
20. According to the SBAR rubric, what should the student pharmacist do after introducing themselves?
- a. State the recommendation immediately.
- b. Verify the patient’s name and date of birth.
- c. Ask the provider if they have time to talk.
- d. Provide the patient’s room number.
Answer: b. Verify the patient’s name and date of birth.
21. The patient’s social history (e.g., alcohol, tobacco use) is documented in which section of the SOAP note?
- a. S – Subjective
- b. O – Objective
- c. A – Assessment
- d. P – Plan
Answer: a. S – Subjective
22. Which of the following is NOT a medication therapy problem (MTP)?
- a. Needs additional drug therapy.
- b. Adverse drug reaction.
- c. Patient’s insurance provider.
- d. Dosage too high.
Answer: c. Patient’s insurance provider.
23. The “Situation” in SBAR should be:
- a. A long, detailed story.
- b. A concise, one-sentence statement of the problem.
- c. The pharmacist’s recommendation.
- d. The patient’s complete past medical history.
Answer: b. A concise, one-sentence statement of the problem.
24. The Pharmacists’ Patient Care Process (PPCP) aligns with the SOAP note format. The “Collect” step of the PPCP corresponds to which parts of the SOAP note?
- a. Assessment and Plan
- b. Subjective and Objective
- c. Plan only
- d. Assessment only
Answer: b. Subjective and Objective
25. A pharmacist writing a SOAP note for a patient with renal changes would need to document the estimated CrCl in which section?
- a. Subjective
- b. Objective
- c. Assessment
- d. Plan
Answer: b. Objective
26. Why is it important to prioritize the problems in the “Assessment” section?
- a. To make the note appear more organized.
- b. To address the most urgent and clinically significant issues first.
- c. The first problem listed is the only one the provider will read.
- d. To ensure the note meets a minimum word count.
Answer: b. To address the most urgent and clinically significant issues first.
27. Information obtained from a physical exam, such as “2+ pitting edema in lower extremities,” is what type of data?
- a. Subjective
- b. Objective
- c. Assessment
- d. A recommendation
Answer: b. Objective
28. An effective “Plan” should always include specific parameters for:
- a. Patient satisfaction.
- b. Hospital finances.
- c. Efficacy and safety monitoring.
- d. Staffing levels.
Answer: c. Efficacy and safety monitoring.
29. What is a key difference between a SOAP note and an SBAR communication?
- a. SOAP is verbal, while SBAR is written.
- b. SBAR is for non-urgent issues only.
- c. SOAP is a comprehensive documentation format, while SBAR is a tool for brief, direct communication.
- d. Only physicians can use SOAP notes.
Answer: c. SOAP is a comprehensive documentation format, while SBAR is a tool for brief, direct communication.
30. Documenting patient care recommendations in the EHR is a listed objective for which course?
- a. PHA5164L: Professional Skills Laboratory 4
- b. PHA5163L: Professional Skills Lab 3
- c. Both a and b
- d. Neither a nor b
Answer: c. Both a and b
31. The statement “Patient’s A1c is 9.2%, indicating uncontrolled type 2 diabetes” belongs in which section?
- a. Subjective
- b. Objective
- c. Assessment
- d. Plan
Answer: c. Assessment
32. “Continue current medications” is an acceptable plan if:
- a. You are not sure what to do.
- b. The assessment determines that the current therapy is appropriate and meeting goals.
- c. The patient refuses any changes.
- d. It is never an acceptable plan.
Answer: b. The assessment determines that the current therapy is appropriate and meeting goals.
33. What is the best way to start the “Assessment” portion of an SBAR communication to a physician?
- a. “I’m not sure, but…”
- b. “The nurse told me that…”
- c. “My assessment is that the patient’s acute kidney injury is likely due to…”
- d. “What do you want to do?”
Answer: c. “My assessment is that the patient’s acute kidney injury is likely due to…”
34. A patient’s chief complaint (CC) is documented in the:
- a. Subjective section.
- b. Objective section.
- c. Assessment section.
- d. Plan section.
Answer: a. Subjective section.
35. A monitoring parameter like “Check SCr in 3 days” is designed to assess:
- a. Efficacy of the drug.
- b. Safety and potential adverse effects of the drug.
- c. Patient adherence.
- d. The cost of the drug.
Answer: b. Safety and potential adverse effects of the drug.
36. A pharmacist’s SOAP note is a part of the patient’s permanent medical record and can be used as a legal document.
- a. True
- b. False
Answer: a. True
37. Which statement is an example of a well-defined medication therapy problem in the Assessment?
- a. “Patient has hypertension.”
- b. “Patient’s lisinopril.”
- c. “Needs additional drug therapy: Patient with osteoporosis (FRAX score >20%) not on pharmacologic therapy.”
- d. “The patient feels bad.”
Answer: c. “Needs additional drug therapy: Patient with osteoporosis (FRAX score >20%) not on pharmacologic therapy.”
38. The “Background” of an SBAR communication should be:
- a. A complete life story of the patient.
- b. Concise and directly relevant to the current situation.
- c. A list of all medications, including ones from years ago.
- d. The same as the “Situation.”
Answer: b. Concise and directly relevant to the current situation.
39. A review of systems (ROS) where a provider asks a patient about symptoms in different body systems is documented as:
- a. Subjective information.
- b. Objective information.
- c. The physical exam.
- d. The assessment.
Answer: a. Subjective information.
40. A plan to provide patient education on using a new inhaler belongs in which section of the SOAP note?
- a. S – Subjective
- b. O – Objective
- c. A – Assessment
- d. P – Plan
Answer: d. P – Plan
41. The Patient Care 4 syllabus specifies that the SOAP note assignment will focus on:
- a. Pediatric dosing.
- b. Medication adjustment in patients with renal changes.
- c. Management of diabetes.
- d. Patient counseling.
Answer: b. Medication adjustment in patients with renal changes.
42. Which of the following is NOT an appropriate part of the “Plan” section?
- a. Initiate metformin 500 mg PO BID.
- b. Counsel patient on signs of hypoglycemia.
- c. Patient has a history of type 2 diabetes.
- d. Check A1c in 3 months.
Answer: c. Patient has a history of type 2 diabetes.
43. A pharmacist uses the SBAR format to call a physician about a patient’s subtherapeutic INR. The “Situation” would be:
- a. “This is the pharmacist calling about Jane Doe, whose INR today is 1.2.”
- b. “Jane Doe is a 72-year-old female admitted for pneumonia with a history of atrial fibrillation on warfarin.”
- c. “I believe the patient’s INR is subtherapeutic, increasing her risk of stroke.”
- d. “I recommend we increase her weekly warfarin dose by 10% and recheck the INR in 3-5 days.”
Answer: a. “This is the pharmacist calling about Jane Doe, whose INR today is 1.2.”
44. Where would you document a patient’s family history of premature coronary artery disease?
- a. Objective
- b. Subjective (specifically, Family History)
- c. Assessment
- d. Plan
Answer: b. Subjective (specifically, Family History)
45. Your “Assessment” of a patient’s therapy should always be supported by:
- a. Your personal opinion.
- b. What the patient wants to hear.
- c. Evidence from the Subjective and Objective data.
- d. Information from a different patient’s chart.
Answer: c. Evidence from the Subjective and Objective data.
46. A “templated format” for a SOAP note helps to:
- a. Make the note more difficult to write.
- b. Ensure all necessary components are included and organized.
- c. Limit the amount of information you can include.
- d. Eliminate the need for an assessment.
Answer: b. Ensure all necessary components are included and organized.
47. When using SBAR, it is important to have all relevant information (e.g., lab results, medication list) available before you make the call.
- a. True
- b. False
Answer: a. True
48. Identifying a medication therapy problem like “Dose too low” falls under which step of the Pharmacists’ Patient Care Process?
- a. Collect
- b. Assess
- c. Plan
- d. Implement
Answer: b. Assess
49. The overall purpose of a SOAP note in an interprofessional setting is to:
- a. Justify the pharmacist’s position on the team.
- b. Provide a clear, logical, and defensible record of a pharmacist’s cognitive work and care plan.
- c. Create a document that only other pharmacists can understand.
- d. Fulfill a daily task requirement.
Answer: b. Provide a clear, logical, and defensible record of a pharmacist’s cognitive work and care plan.
50. What does the “More” in “SOAP Notes and More” likely refer to in the context of the skills lab curriculum?
- a. Different types of sandwiches.
- b. Other forms of clinical communication and documentation, like SBAR.
- c. Advanced calculation methods.
- d. The history of pharmacy.
Answer: b. Other forms of clinical communication and documentation, like SBAR.