Which component of SOAP notes contains the patient’s own descriptions of symptoms?

Which component of SOAP notes contains the patient’s own descriptions of symptoms?

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

Answer: (A)

In SOAP notes, the part that captures the patient’s own descriptions of symptoms is the subjective section. This is where the patient tells you what they’re experiencing—the chief complaint, onset, quality, intensity, duration, and factors that worsen or relieve symptoms—using their own words. The clinician records this information as reported by the patient, not as measured or observed data. By contrast, the objective section includes measurable or observable findings like vital signs, physical exam results, and test data. The assessment is the clinician’s diagnosis or impression based on combining subjective and objective information, and the plan outlines treatment and follow-up. For example, a patient saying, “I’ve had a throbbing headache for two days, worse in bright light,” belongs in the subjective portion, while the measured blood pressure or a normal neurological exam would appear in the objective portion.

In SOAP notes, the part that captures the patient’s own descriptions of symptoms is the subjective section. This is where the patient tells you what they’re experiencing—the chief complaint, onset, quality, intensity, duration, and factors that worsen or relieve symptoms—using their own words. The clinician records this information as reported by the patient, not as measured or observed data. By contrast, the objective section includes measurable or observable findings like vital signs, physical exam results, and test data. The assessment is the clinician’s diagnosis or impression based on combining subjective and objective information, and the plan outlines treatment and follow-up. For example, a patient saying, “I’ve had a throbbing headache for two days, worse in bright light,” belongs in the subjective portion, while the measured blood pressure or a normal neurological exam would appear in the objective portion.