In SOAP notes, what category does the physical exam findings belong to?

In SOAP notes, physical exam findings are categorized as objective data. This is because the objective section encompasses measurable and observable information that can be verified by others, such as vital signs, physical examination results, laboratory test results, and imaging studies. This information is critical in providing a clear picture of the patient's current health status for anyone reviewing the note, irrespective of their interaction with the patient.

The other sections of a SOAP note serve distinct purposes. The subjective section includes the patient's personal reports about their symptoms and feelings, while the assessment section allows the healthcare professional to analyze and interpret the subjective and objective data to form a diagnosis or clinical impression. The plan section outlines the steps for treatment and follow-up based on the assessment. Thus, the identification of physical exam findings in the objective category is essential for effective clinical documentation and communication.