Which information belongs in the subjective portion of a SOAP note?

Which information belongs in the subjective portion of a SOAP note?

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

Answer: (A)

In the Subjective portion, you record information provided directly by the patient or their caregiver—their own reports about symptoms, history, and how the issue affects them. This includes what the patient describes about pain or other symptoms (onset, location, quality, intensity, duration), what makes it better or worse, any prior treatments, relevant medical history, and how the problem impacts daily activities and goals. This is the space for the patient’s perspective, not for measured data or the clinician’s judgments. Other sections cover different kinds of data: objective contains tests, measurements, and observable findings; assessment is the clinician’s diagnosis or impression; plan outlines treatment steps and follow-up.

In the Subjective portion, you record information provided directly by the patient or their caregiver—their own reports about symptoms, history, and how the issue affects them. This includes what the patient describes about pain or other symptoms (onset, location, quality, intensity, duration), what makes it better or worse, any prior treatments, relevant medical history, and how the problem impacts daily activities and goals. This is the space for the patient’s perspective, not for measured data or the clinician’s judgments. Other sections cover different kinds of data: objective contains tests, measurements, and observable findings; assessment is the clinician’s diagnosis or impression; plan outlines treatment steps and follow-up.