What should be documented in the “Subjective” section of S.O.A.P. notes?

In the "Subjective" section of S.O.A.P. notes, documenting the patient’s feelings and perceptions is essential as it provides insight into the patient’s experience and current condition from their perspective. This section allows the patient to express how they feel about their symptoms or the impact of their condition on their daily life, which can include pain levels, emotional state, and any concerns they may have. Capturing this information is critical for understanding the overall context of the patient's health status and helps guide treatment decisions.

The other aspects mentioned, such as objective findings, assessment and diagnosis, and future treatment plans, belong to the respective sections of the S.O.A.P. format. Objective findings are documented in the "Objective" part, while assessments and diagnoses are listed in the "Assessment" section. Future treatment plans belong in the "Plan" section. These distinctions are vital to ensure clarity and thoroughness in patient documentation.