What is included in the 'subjective' part of the SOAP note?

• A. Clinician's observations and measurements
• B. Patient's reported symptoms and history
• C. Outcome assessment results
• D. Laboratory test results

Answer: (B)

The 'subjective' part of the SOAP note primarily focuses on the patient’s perspective, including their reported symptoms, feelings, and history. This section captures information shared by the patient, which is crucial for understanding their experiences and perceptions regarding their health condition. It typically includes descriptions of pain, emotional status, and any pertinent medical history that the patient believes is relevant to their current health.

The other sections of the SOAP note serve different functions: the 'objective' part documents clinician observations and measurable data, the 'assessment' part evaluates the subjective and objective information to formulate a diagnosis, and the 'plan' part details the treatment plan and follow-up activities. Each section plays a distinct role in the clinical documentation process, with the subjective section specifically emphasizing the patient's viewpoint.