In a SOAP note, which section would document patient dizziness?

In a SOAP note, which section would document patient dizziness?

• A. Subjective
• B. Objective
• C. Plan
• D. Assessment

Answer: (A)

Dizziness is a symptom reported by the patient, not something measured or observed directly by the clinician, so it fits in the Subjective portion of a SOAP note. The Subjective section is where you record the patient's own words, including the chief complaint, history of present illness, and symptoms captured in the Review of Systems. In contrast, the Objective section holds measurable data and clinician-observed findings, while the Assessment contains your diagnostic impressions and differential, and the Plan outlines treatment. If dizziness is also observed during the exam, those objective signs would go in the Objective section, but the patient’s dizziness as reported is documented in Subjective.

Dizziness is a symptom reported by the patient, not something measured or observed directly by the clinician, so it fits in the Subjective portion of a SOAP note. The Subjective section is where you record the patient's own words, including the chief complaint, history of present illness, and symptoms captured in the Review of Systems. In contrast, the Objective section holds measurable data and clinician-observed findings, while the Assessment contains your diagnostic impressions and differential, and the Plan outlines treatment. If dizziness is also observed during the exam, those objective signs would go in the Objective section, but the patient’s dizziness as reported is documented in Subjective.