In the subjective portion of a SOAP note, which information goes there?

In the subjective portion of a SOAP note, which information goes there?

• A. Everything the patient tells you
• B. The clinician's diagnosis
• C. Tests and evaluative measures
• D. The plan of care

Answer: (A)

The subjective portion is where you record the patient’s own reports about their symptoms, history, and experience. It includes what the patient describes about pain or functional limitations, onset and duration, location and quality of symptoms, aggravating or relieving factors, previous injuries or treatments, medications, and any relevant personal or social history that affects their condition. This is the patient’s perspective and narrative, not measured data. The other parts belong elsewhere: the clinician’s measurements, tests, and observations go in the objective section; the clinician’s diagnosis or impression is in the assessment; and the plan for treatment, education, and follow-up goes in the plan.

The subjective portion is where you record the patient’s own reports about their symptoms, history, and experience. It includes what the patient describes about pain or functional limitations, onset and duration, location and quality of symptoms, aggravating or relieving factors, previous injuries or treatments, medications, and any relevant personal or social history that affects their condition. This is the patient’s perspective and narrative, not measured data.

The other parts belong elsewhere: the clinician’s measurements, tests, and observations go in the objective section; the clinician’s diagnosis or impression is in the assessment; and the plan for treatment, education, and follow-up goes in the plan.