What is the first step in the SOAP note format?

The first step in the SOAP note format is the Subjective section. This portion is crucial as it captures the patient's personal experience regarding their condition. It includes information such as symptoms, feelings, and perspectives on their health status, which the patient communicates to the healthcare provider. This helps in forming a holistic view of the patient's situation and sets the stage for the subsequent sections of the note.

By starting with the subjective experience, it allows the clinician to understand the patient's perspective and prioritize issues that may require urgent attention or further inquiry. It ensures that the patient's voice is included in their care, which can lead to improved communication and a stronger patient-provider relationship. The other components, while essential, follow this initial understanding, where the Objective section presents measurable data, the Assessment provides the clinician's professional interpretation, and the Plan outlines the intended course of action based on the gathered information.