TY  - CHAP
M1  - Book, Section
TI  - The SOAP Note: Writing Subjective (S), Including the Review of Systems
A1  - Kettenbach, Ginge
A1  - Schlomer, Sarah L.
A1  - FitzGerald, Jill
PY  - 2016
T2  - Writing Patient/Client Notes
AB  - 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.  
SN  - 
PB  - F. A. Davis Company
CY  - New York, NY
Y2  - 2024/04/17
UR  - fadavispt.mhmedical.com/content.aspx?aid=1180747646
ER  -