Advanced Health Assessment Practice Exam

Where in the SOAP note would you document the history for the patient?

1. S - Subjective

2. O - Objective

3. A - Assessment

4. P - Plan

The correct answer is: S - Subjective

The correct place to document the history for the patient in a SOAP note is in the Subjective section. This part of the note is dedicated to the patient's personal account of their symptoms, experiences, and feelings, which provides context for their health condition. It includes information such as the patient's chief complaint, past medical history, family history, social history, and any other relevant personal information that is shared by the patient. The Subjective section is critical because it captures the patient's perspective, allowing healthcare providers to understand how the patient perceives their health and wellness. In contrast, the other sections serve different purposes: the Objective section documents observable and measurable data, the Assessment section synthesizes the subjective and objective findings into a diagnosis, and the Plan outlines the proposed interventions or treatments. Each section plays a crucial role, but when it comes to gathering the patient’s history, the Subjective section is where this information is thoroughly documented.