What should be included in the "Subjective" portion of a SOAP note?

The "Subjective" portion of a SOAP note is dedicated to capturing the patient’s perspectives, including their own descriptions of symptoms, feelings, and concerns. This section reflects the patient’s experiences in their own words, allowing healthcare providers to understand the context of their illness or condition from the patient's viewpoint.

In clinical practice, the Subjective portion plays a crucial role in the overall assessment, as it informs the provider about the patient's chief complaints and helps establish a rapport by valuing the patient's insights. This information is foundational for subsequent steps in the SOAP note, including the assessment and plan, as it directly influences the provider's understanding and interpretation of the patient's health status. The emphasis is on the patient's narrative, which is key for accurate diagnosis and effective communication.

For example, the patient might describe how their symptoms affected their daily life or express any concerns regarding their treatment, which are essential for comprehensive care.