In the SOAP note, which part covers what the patient tells you?

In the SOAP note, which part covers what the patient tells you?

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

Answer: (A)

The main idea is that the patient’s own words and reported history belong in the part of the SOAP note that is devoted to their narrative. This section captures what the patient describes about their symptoms, how long they’ve had them, how they feel, where they hurt, when they started, what makes them better or worse, and how the symptoms affect daily life. It also includes information the patient provides about medications, allergies, and relevant personal or social history as they report it. That’s why this part is the best answer: it specifically houses the patient’s subjective experience and report, rather than anything measured or observed by you. Objective data come from your physical exam, tests, and measurements. The assessment is your clinical impression and diagnosis, and the plan outlines the treatment and next steps. If the patient’s words about their symptoms and history are what you’re focusing on, this is the section that fits.

The main idea is that the patient’s own words and reported history belong in the part of the SOAP note that is devoted to their narrative. This section captures what the patient describes about their symptoms, how long they’ve had them, how they feel, where they hurt, when they started, what makes them better or worse, and how the symptoms affect daily life. It also includes information the patient provides about medications, allergies, and relevant personal or social history as they report it.

That’s why this part is the best answer: it specifically houses the patient’s subjective experience and report, rather than anything measured or observed by you. Objective data come from your physical exam, tests, and measurements. The assessment is your clinical impression and diagnosis, and the plan outlines the treatment and next steps. If the patient’s words about their symptoms and history are what you’re focusing on, this is the section that fits.