In a SOAP note, which section documents the patient's reported symptoms and experiences?

In a SOAP note, which section documents the patient's reported symptoms and experiences?

• A. Objective
• B. Subjective
• C. Assessment
• D. Plan

Answer: (B)

In a SOAP note, patient-reported symptoms and experiences are documented in the subjective section. This part captures what the patient tells you about how they feel, when symptoms began, how severe they are, what makes them better or worse, and any related history or context the patient provides. Include details like onset, duration, quality (e.g., throbbing, sharp), intensity, radiation, and factors that affect symptoms, and you can use direct quotes when helpful to preserve the patient’s exact wording. This is distinct from the objective section, which is where you record measurable or observable data you obtain through examination, tests, or measurements (vital signs, physical findings, lab results). The assessment combines all data to form a clinical impression, and the plan outlines what you intend to do next (treatment, referrals, follow-up). For example, a patient reporting a sudden headache with described triggers and duration belongs in subjective, while the clinician’s findings like “normal neurological exam” belong in objective.

In a SOAP note, patient-reported symptoms and experiences are documented in the subjective section. This part captures what the patient tells you about how they feel, when symptoms began, how severe they are, what makes them better or worse, and any related history or context the patient provides. Include details like onset, duration, quality (e.g., throbbing, sharp), intensity, radiation, and factors that affect symptoms, and you can use direct quotes when helpful to preserve the patient’s exact wording.

This is distinct from the objective section, which is where you record measurable or observable data you obtain through examination, tests, or measurements (vital signs, physical findings, lab results). The assessment combines all data to form a clinical impression, and the plan outlines what you intend to do next (treatment, referrals, follow-up). For example, a patient reporting a sudden headache with described triggers and duration belongs in subjective, while the clinician’s findings like “normal neurological exam” belong in objective.