In which section of a SOAP note should a patient's chief complaint, such as stomach pain, be documented?

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Prepare for the West-MEC Medical Assisting Technical Skills Assessment. Study with flashcards and multiple choice questions, with comprehensive hints and explanations. Get exam ready!

Multiple Choice

In which section of a SOAP note should a patient's chief complaint, such as stomach pain, be documented?

Explanation:
The chief complaint is the patient's own description of why they came in, so it belongs in the subjective portion. This section holds patient-reported information, including the chief complaint, history of present illness, and symptoms as described by the patient. The objective portion is for what you observe or measure (vital signs, exam findings, labs), the assessment is the clinician’s diagnosis or differential, and the plan covers treatment and next steps. So a stomach pain described by the patient should be documented in the subjective section.

The chief complaint is the patient's own description of why they came in, so it belongs in the subjective portion. This section holds patient-reported information, including the chief complaint, history of present illness, and symptoms as described by the patient. The objective portion is for what you observe or measure (vital signs, exam findings, labs), the assessment is the clinician’s diagnosis or differential, and the plan covers treatment and next steps. So a stomach pain described by the patient should be documented in the subjective section.

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