Which elements are typically documented in the Subjective portion of a SOAP note?

• A. Chief Complaint and history of present illness
• B. Vital signs and exam findings
• C. Diagnoses and treatment plan
• D. Lab results

Answer: (A)

Subjective data are what the patient reports. The elements documented there capture the patient’s own description of why they are seeking care and how their symptoms have evolved. The Chief Complaint is the patient’s stated reason for the visit, often quoted, while the History of Present Illness expands on that with details about onset, duration, quality, severity, location, timing, context, aggravating or relieving factors, and any associated symptoms, all described from the patient’s perspective. For example, a patient might say they’ve had a three-day history of a throbbing headache that began after long computer work, rated 7 out of 10, worse in bright light, and relieved somewhat by rest. This kind of information is subjective and contrasts with data gathered by the clinician, such as vital signs or exam findings, which are objective. Diagnoses and treatment plans belong in the Assessment and Plan sections, and lab results are objective data obtained from testing. So the typical Subjective documentation is the Chief Complaint and History of Present Illness.