The Subjective (S) part of the note is the section in which the therapist states the information received from the patient or caretaker that is relevant to the patient's present condition. Information may be obtained from a patient's family member or caregiver, with the patient's permission, or when the patient is unable to do so secondary to cognitive and/or medical impairments. Subjective information is necessary to plan the tests and measures that need to be included in the examination of the patient and to justify or explain certain goals that are set with the patient. For example, third-party payors, utilization review auditors, and quality assurance auditors may question a therapist testing a patient's ability and/or teaching a patient to go up and down a flight of 12 steps, unless the Subjective part of the note includes documentation that the patient has 12 steps to enter his home.
At times, information in the Subjective part of the note further clarifies information in the Problem part of the SOAP note. The Problem part of the note includes information obtained solely from the patient's health record. If a therapist clarifies or obtains information that is beyond the information in the patient's health record, the basic information could be listed in the Problem part of the note and the clarifying information could be listed in the Subjective part. Areas where the two parts of the note overlap will be discussed below.
Categorizing Items as Subjective
An item belongs in the Subjective category if any of the following apply:
Demographic information, if the patient (or significant other/caretaker) contributes additional information, such as identifying information about the patient's address, date of birth, biological sex, dominant hand, race, ethnicity, language, education level, advance directive preferences, or reasons for referral to therapy. Such information is usually included in the Problem part of the SOAP Note, not in the Subjective part because this information is usually obtained from the patient's health record. Listing of demographic information varies by facility. In this textbook, all facilities require listing of demographic information under the Problem part of the SOAP note.
The patient (or significant other/caretaker) tells the therapist or assistant about his current conditions/chief concerns. In some facilities, you may see this described as “Chief Complaints.” This information includes the onset date of the problem, any incident that caused or contributed to the onset of the problem, history of similar problems, how the patient is caring for the problem, what makes the problem better and worse, and any other practitioner the patient is seeing for the problem. At the initial evaluation, the patient may report how a level of pain or his level of function has changed since onset of symptoms, or how it has changed after receiving therapy.
The patient (or significant other/caretaker) tells the therapist about his prior and current level of function. This describes the ...