Where should patient-reported information be documented in a SOAP note?

Patient-reported information should be documented in the Subjective section of a SOAP note because this section is specifically designed to record the patient's perspectives, experiences, feelings, and reported symptoms. In clinical practice, understanding a patient's viewpoint is crucial for accurate diagnosis and treatment planning. The Subjective section includes information such as the patient's descriptions of their symptoms (e.g., pain level, emotional state) and any relevant history that they communicate directly. This qualitative data helps healthcare providers understand the patient's condition from their perspective, facilitating more tailored care and interventions.

The other sections of the SOAP note serve different purposes. The Objective section focuses on measurable and observable findings gathered during the examination, the Assessment section is where the clinician synthesizes the information to formulate a diagnosis or problem list, and the Plan outlines the course of action or treatment strategies. Each section plays an important role in overall patient documentation, but the subjective experiences of the patient are best captured in the Subjective section.