What is typically included in the "Objective" section of a SOAP note?

The "Objective" section of a SOAP note contains measurable and observable data regarding the patient’s condition, which includes the healthcare provider's assessments and findings. This section may encompass results from physical examinations, laboratory results, imaging studies, and any other quantifiable information gathered during the clinical encounter. The focus here is on factual data that can be verified, rather than subjective reports from the patient or interpretations based on feelings.

In contrast, the other parts of the SOAP note serve different purposes; for example, the "Subjective" section captures the patient's own descriptions of their symptoms and experiences, while the "Assessment" evaluates and interprets that information. The "Plan" outlines the next steps for treatment, which may include how to address the findings noted in the objective section. Thus, the emphasis on objective, measurable data distinguishes this part of the SOAP note and ensures a systematic approach to patient assessment and care.