Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingEasy
A medical assistant is documenting a patient's visit in an Electronic Health Record (EHR). The patient reports a new symptom of intermittent dizziness. Which section of the SOAP note should this information be recorded?
- ASubjective
- BObjective
- CAssessment
- DPlan
Show answer & explanationAnswer & explanation
Correct answer: A. Subjective
The 'Subjective' section of a SOAP note is where information reported by the patient is documented. This includes symptoms, chief complaint, medical history, and anything the patient states about their condition.
Why the other options are wrong
- B. Objective refers to measurable and observable data, like vital signs or exam findings.
- C. Assessment is the physician's diagnosis or impression of the patient's condition.
- D. Plan outlines the next steps for treatment, testing, or referrals.
SOAP Note
A method of documentation used by healthcare providers to record patient information in a structured, organized way.
- S: Subjective (patient's complaints)
- O: Objective (measurable data)
- A: Assessment (diagnosis)
- P: Plan (treatment strategy)
Memory trick: SOAP up your notes, start with S for what the patient SAYS!