In SOAP documentation, which section captures the patient's own description of the injury and symptoms?

In SOAP documentation, which section captures the patient's own description of the injury and symptoms?

• A. Assessment/Diagnosis
• B. Plan for treatment
• C. Subjective history
• D. Objective findings

Answer: (C)

The patient’s own description of what happened and what they’re feeling goes in the subjective history. This section captures the chief complaint, mechanism of injury, onset and timing, location, quality and intensity of pain, and any other symptoms in the patient’s own words, along with relevant history (previous injuries, meds, allergies, activity level). This information guides how you interpret the injury and plan the exam and treatment. Objective findings are what you measure or observe during the exam (like swelling, ROM, strength, and special tests), while the assessment is your clinical interpretation and the plan outlines the next steps. So the patient’s description of their injury and symptoms is best documented in the subjective history.

The patient’s own description of what happened and what they’re feeling goes in the subjective history. This section captures the chief complaint, mechanism of injury, onset and timing, location, quality and intensity of pain, and any other symptoms in the patient’s own words, along with relevant history (previous injuries, meds, allergies, activity level). This information guides how you interpret the injury and plan the exam and treatment. Objective findings are what you measure or observe during the exam (like swelling, ROM, strength, and special tests), while the assessment is your clinical interpretation and the plan outlines the next steps. So the patient’s description of their injury and symptoms is best documented in the subjective history.