RT Book, Section A1 Kettenbach, Ginge A1 Schlomer, Sarah L. A1 FitzGerald, Jill SR Print(0) ID 1180747646 T1 The SOAP Note: Writing Subjective (S), Including the Review of Systems T2 Writing Patient/Client Notes YR 2016 FD 2016 PB F. A. Davis Company PP New York, NY SN 9780803638204 LK fadavispt.mhmedical.com/content.aspx?aid=1180747646 RD 2024/03/29 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.