What kind of information belongs in the Subjective (S) section of a SOAP note?
Answer
Self-reported symptoms and experiences since the last visit.
The Subjective section captures the perspective directly reported by the patient or client. This includes their feelings, concerns, self-reported symptoms, and experiences occurring between sessions. In counseling, this might detail mood or sleep quality; in physical therapy, it encompasses reports of pain levels and functional limitations as described by the patient. It is strictly the patient's narrative voice, preserved by recording what they stated rather than what the clinician observed or concluded.
Related Questions
What is the primary function of the SOAP note approach in clinical documentation?What kind of information belongs in the Subjective (S) section of a SOAP note?In Physical Therapy documentation, what characterizes the Objective (O) section?What mental health concept requires clinical judgment within the Assessment (A) section?What concrete elements must the Plan (P) section detail for mental health clients?How does the emphasis on the Objective (O) section differ between Physical Therapy and other fields?Which sections of the SOAP note do insurance providers examine to verify medical necessity for reimbursement?Which statement exemplifies data correctly placed in the Subjective (S) section?According to the PT model, what must the Assessment (A) logically connect?How does the structure of the SOAP note promote internal reflection by the clinician?