If a patient reports dizziness after taking medication, where should this be documented in a SOAP note?

If a patient reports dizziness after taking medication, where should this be documented in a SOAP note?

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

Answer: (B)

Dizziness reported by the patient is a symptom they describe, so it goes in the Subjective portion. In SOAP notes, Subjective captures what the patient says in their own words—symptoms, concerns, and history—since these are not directly measured or observed by the clinician. Objective is for measurable or observable data, like vital signs or physical exam findings. If you later observe signs during an exam (for example, an unsteady gait), those observations would appear in the Objective section. The rest of the SOAP note—Assessment and Plan—would address the clinician’s interpretation and the next steps, such as evaluating medication side effects or adjusting treatment.

Dizziness reported by the patient is a symptom they describe, so it goes in the Subjective portion. In SOAP notes, Subjective captures what the patient says in their own words—symptoms, concerns, and history—since these are not directly measured or observed by the clinician. Objective is for measurable or observable data, like vital signs or physical exam findings. If you later observe signs during an exam (for example, an unsteady gait), those observations would appear in the Objective section. The rest of the SOAP note—Assessment and Plan—would address the clinician’s interpretation and the next steps, such as evaluating medication side effects or adjusting treatment.