Which item would NOT normally be included in the Plan section?

• A. Follow-up plans
• B. Medication dosages
• C. Patient education
• D. Chief Complaint

Answer: (D)

In documenting a SOAP note, the Plan section lists actions to address the patient’s problems—things you’ll do next. This includes follow-up plans, medication choices with dosages and instructions, patient education tailored to the patient, and any tests, referrals, or monitoring you’re instituting. The Chief Complaint, on the other hand, is the reason the patient sought care and is captured in the Subjective (and summarized in the Assessment) to anchor the problems. It provides context for why the visit occurred but it isn’t an action you plan to take. So the item that would not normally be included in the Plan is the Chief Complaint.