Documentation is one of the most important responsibilities in healthcare, and the quality of those notes can greatly affect treatment decisions, patient outcomes, and clinical communication. Among all documentation styles, SOAP notes remain one of the most widely used formats. They help organize patient information in a clear and professional way. The very first part of a SOAP note, the Subjective section, lays the foundation for everything that follows because it captures the patient’s personal experience in their own words. It is where the clinician listens, asks questions, and records the patient’s symptoms, concerns, and goals before any physical examination or testing occurs.
A well-written subjective note does more than describe “what the patient says.” It guides the rest of the clinical process by directing what needs to be examined, measured, and treated next. When written correctly, it improves diagnostic accuracy, supports clinical decision-making, and builds trust between the patient and provider.
What Is the Subjective Section in SOAP Notes?
The Subjective section is the first part of a SOAP note, and it captures the patient’s personal story about their symptoms or condition. It includes anything the patient feels, notices, or describes about their health. This information comes directly from the patient and is not proven through tests or physical examination.
Unlike the objective section, the subjective part does not contain measurements such as blood pressure, lab results, or physician observations. Instead, it focuses on the patient’s thoughts, emotions, pain levels, history of the problem, and the impact on daily life. These details help the clinician understand what the patient is experiencing on a personal level.
This section acts as the patient’s voice in the medical record. The clinician’s role is to listen actively, ask relevant questions, and document the information that matters most for diagnosis and treatment. A clear and accurate subjective note guides what needs to be examined next, making it an essential starting point for quality clinical care.
Why Is Subjective Information Important?
The Subjective part is important helps the clinician understand the patient’s:
- pain level
- emotional feelings
- symptoms
- personal concerns
- daily challenges
- goals and expectations
It helps in decision-making because patients know their bodies and emotions best, and their story gives direction to the treatment plan.
For example, if a patient says, “My back hurts more when I sit for long hours,” this information helps the provider know what to check and what to treat.
What Should Be Included in the Subjective Section?
The Subjective part should include:
Main Complaint (Reason for Visit)
This is a short statement describing the main problem the patient wants help with.
Example:
- “My chest hurts when I walk fast.”
History of Present Illness (Details About the Problem)
This includes how the problem started, when it happens, how long it lasts, and what makes it better or worse.
Use simple questions like:
- When did it start?
- What makes it better?
- Does anything make it worse?
Symptoms Described in the Patient’s Own Words
Write exactly how the patient explains symptoms. Use quotation marks if necessary.
Example:
- Patient states, “I feel dizzy when I stand up quickly.”
Pain Level (If Applicable)
Pain can be recorded using a pain scale from 0 to 10.
Example:
- “Pain level: 7/10.”
Medical History Related to the Complaint
This includes allergies, past illnesses, surgeries, or similar problems in the past.
Medication Information (If Relevant)
Ask if the patient is taking any medicine and if it helps.
Lifestyle Impact / Daily Functioning
Describe how the problem affects their daily life.
Example:
- “Patient reports difficulty sleeping because of leg pain.”
Patient Goals
What does the patient want? What are they hoping to fix?
Example:
- “Patient wants to walk without pain.”
What Should NOT Be Included in the Subjective Section?
The Subjective section should not include measurements, tests, or what the clinician observes. Those belong to the Objective section.
❌ Do not include:
- Vital signs (e.g., blood pressure, temperature)
- Physical exam findings
- Lab test results
- Provider opinions
❌ Do not write vague words without quoting the patient.
Example:
Instead of writing “Patient is sad.”
Write: “Patient says, ‘I feel sad all the time.’”
How to Write Better Subjective Notes
To write clearer and more useful subjective notes, focus on capturing only information that comes directly from the patient and relates to the main problem. Use simple, concise wording and include the patient’s exact phrases when they describe pain, emotions, or specific sensations. Ask open questions to learn when the issue began, what makes it better or worse, and how it affects daily life. Always record pain levels using a 0–10 scale when relevant, and include brief medical history or medications only if they relate to the current complaint. By listening carefully and documenting accurately without adding personal interpretations, clinicians can create strong subjective notes that guide accurate diagnosis and better treatment decisions.
| Tip | Explanation |
|---|---|
| Listen carefully | Let the patient talk without interruption at first. |
| Ask simple, open questions | Helps get clear and wide information. |
| Use patient quotes | Keeps information accurate. |
| Focus on the main problem | Keep the note short and relevant. |
| Record pain clearly | Use the pain scale 0–10. |
| Ask about daily activities | Learn how symptoms affect life. |
Example Questions to Ask for Subjective Notes
You can ask questions like:
General Questions
- “When did the problem start?”
- “Where do you feel the pain?”
- “What makes it better or worse?”
Pain Questions
- “How strong is your pain from 0 to 10?”
- “Is the pain sharp or dull?”
Mental Health Questions
- “How are you feeling emotionally?”
- “Do you have trouble sleeping?”
Daily Life Questions
- “Does the problem stop you from working?”
- “Does it affect your mood or relationships?”
SOAP Notes Subjective Examples
Back Pain (Physical Therapy / Primary Care)
S: Patient reports lower back pain for 10 days. Pain started after lifting heavy boxes at work. Patient describes pain as “sharp and tight,” especially when bending forward or sitting for long periods. Pain rated 7/10. Heat reduces pain slightly. Patient denies numbness or tingling in legs. Patient wants to return to work without pain.
Severe Abdominal Pain (Emergency Care)
S: Patient reports sudden, severe abdominal pain beginning 2 hours ago. Pain is located in the lower right abdomen and is described as “stabbing and unbearable.” Pain rated 9/10 and worsens with movement. Patient reports nausea and vomited once on the way to the hospital. No appetite since morning. Patient denies diarrhea or constipation. No history of similar symptoms. Denies recent injury or trauma. Patient reports fever and chills since this morning. Patient says, “I can’t stand straight, it hurts too much.” Patient wants relief from pain and answers regarding the cause.
Anxiety (Mental Health Counseling)
S: Patient reports feeling anxious every night before sleeping. Patient states, “I keep thinking something bad will happen.” Difficulty falling asleep and wakes up frequently. Reports chest tightness and racing thoughts but no chest pain or breathing difficulty. Anxiety symptoms started 3 months ago after job stress increased. Patient wants to learn coping skills and improve sleep.
Ear Pain in Child (Pediatric Visit)
S: Mother reports child complaining of right ear pain for 2 days. Pain worsens when lying down. Child says, “My ear feels full.” Fever last night, mild cough, and reduced appetite. No known allergies. Child woke up crying due to pain. Parent wants pain relief and wants to know if infection is present.
Recurring Headaches (General Medical Clinic)
S: Patient reports recurring headaches for the past 4 weeks. Pain is mainly on the forehead and behind the eyes. Patient describes the pain as “pressure and tightness.” Headaches occur mostly in the afternoon and worsen with long screen time at work. Patient rates pain 4/10 to 7/10 depending on the day. Over-the-counter pain medicine gives temporary relief. Patient reports recent stress due to work deadlines and reduced sleep (5–6 hours per night). No nausea or vomiting. Light sensitivity noted occasionally. Patient wants to reduce headaches and improve daily functioning.
Knee Injury (Sports Medicine)
S: Patient reports left knee pain after playing basketball yesterday. Patient says knee “feels unstable” and “hurts when walking downstairs.” Pain rated 6/10 when moving, 2/10 at rest. Swelling noticed last night. Ice helped reduce pain slightly. Patient denies hearing a pop during injury. Patient wants to return to sports as soon as possible.
Common Mistakes in Writing Subjective Notes
Many clinicians make the mistake of including their own opinions, exam findings, or assumptions in the subjective section, even though it should contain only what the patient reports. Another common error is using vague language without quoting the patient’s exact words, which can change the meaning of the complaint and lead to misunderstandings. Some notes also become unclear because they include too much unrelated detail, while others leave out important information such as pain level, symptom duration, or impact on daily activities. To avoid these mistakes, subjective notes should stay focused on the patient’s voice, use clear and concise wording, and record only information that directly supports accurate diagnosis and treatment.
| Mistake | Why it’s wrong |
|---|---|
| Writing your opinion | Subjective must be only the patient’s experience. |
| Adding physical findings | Those belong in Objective. |
| Using vague words without quotes | Important words must reflect patient’s exact language. |
| Writing too much detail not related to complaint | Keep it focused on the main problem. |
How to Keep Subjective Notes Short and Useful
You do not need to write every word the patient says. Choose only the important information related to the reason for the visit.
Use short phrases, not long sentences.
Example:
Instead of:
“The patient said they were feeling a little pain but it only happens sometimes when they move their arm above their head and it gets worse and they don’t know why.”
Write:
“Patient reports shoulder pain when lifting arm above head. Pain 4/10.”
Short, clear notes save time and improve communication.
Patient Quotes: When to Use Them
Use quotes when:
- the patient uses strong emotional or descriptive words
- the wording could change the meaning
- the wording is medically or legally important
Examples of quotes:
- “I feel like I am going to die.”
- “My knee feels like rocks are inside.”
- “I just cannot stop crying.”
This protects both the clinician and the patient by recording exact words.
Subjective in Telehealth Sessions
For online or phone sessions, the Subjective section is even more important because the clinician cannot observe the patient as clearly.
Make sure to:
- ask clear questions
- record the patient’s words carefully
- ask about environment (home stress, work stress, daily activity changes)
Patient-Centered Subjective Notes
Always remember: The subjective note should represent how the patient views their health.
This helps build trust, improves diagnosis, and supports good treatment planning.
A patient-centered approach means:
- respecting patient words
- listening without judgment
- writing only what the patient shares
The Bottom Line
The Subjective section of a SOAP note is one of the most important parts of clinical documentation because it captures the patient’s own story in their own words. It gives the healthcare professional a clear understanding of how the patient feels, what they are experiencing, and how their condition affects daily life. These details cannot be measured with tools or tests, but they give a strong direction for diagnosis and treatment. When we listen carefully, ask questions, write clearly, and use patient quotes when needed, we ensure that the note reflects the patient’s true problem.
Good subjective documentation builds trust, helps avoid misunderstandings, and leads to better decisions in care. It puts the patient’s voice at the center of the treatment process, which is the real goal of any health visit. Strong subjective notes also support communication between different clinicians, help in legal protection, and save time during follow-ups by giving a clear history. In short, the subjective section is not just a description of symptoms, it is the foundation of compassionate, accurate, and effective healthcare.
Dr. Connor Yost is an Internal Medicine resident at Creighton University School of Medicine in Arizona and an emerging leader in clinical innovation. He currently serves as Chief Medical Officer at Skriber, where he helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Dr. Yost also works as a Strategic Advisor at Doc2Doc, lending his expertise to initiatives that improve financial wellness for physicians and trainees.
His professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare. Dr. Yost is committed to building systems that allow clinicians to spend more time with patients and less on administrative tasks. Outside of medicine, he enjoys photography, entrepreneurship, and family life.
