Advanced Health Assessment Practice Exam

Which information in a SOAP note would be derived from direct observation?

1. Chief complaint

2. Family history

3. Vital signs

4. Social history

The correct answer is: Vital signs

The correct choice is vital signs because they are objective measurements typically obtained through direct observation and assessment during a physical examination. Vital signs, which include parameters such as body temperature, heart rate, respiratory rate, and blood pressure, are quantified and observed directly by the healthcare provider, allowing for an accurate assessment of a patient's physiological state. In contrast, the chief complaint is a subjective report of the patient's main concern, which may not necessarily be observed but rather described by the patient. Family history and social history are derived from patient interviews and recall of personal and familial health backgrounds. These aspects are based on what the patient communicates rather than information that can be directly measured or observed.