In a SOAP record, what term is used for the patient's description of their problem?

In a SOAP record, the term used for the patient's description of their problem is "Subjective." This section captures the patient’s own words regarding their symptoms, feelings, and experiences related to their health issue. It often includes the history of the present illness, any emotional responses, and how the condition affects their daily life. By documenting this perspective, healthcare providers gain insight into the patient's viewpoint, which is crucial for accurate assessment and treatment planning.

The other terms in the SOAP framework each have distinct meanings. The "Objective" section contains measurable or observable data collected during the examination, such as vital signs, lab results, and physical findings. The "Assessment" part provides the clinician’s interpretation of the subjective and objective data, often summarizing the diagnosis or the potential issues identified. Lastly, the "Plan" outlines the intended interventions and treatment strategies based on the assessment. Understanding the roles of these various sections helps ensure comprehensive and effective patient care documentation.