Writing the “S”—Subjective

Chapter 6

Morreale MJ, Borcherding S.The OTA's Guide to Documentation:

Writing SOAP Notes, Third Edition (pp 53-57).

© 2013 SLACK Incorporated.

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The first section of the SOAP note contains SUBJECTIVE information obtained from the client. This “S” sec-tion expresses the client’s perspective regarding his or her condition or treatment. Subjective data is information that cannot necessarily be verified or measured during the intervention session. In this section, the occupational therapy practitioner records the client’s report of limitations, concerns and problems, as well as what the client com-municated that was relevant to treatment. This can include statements regarding significant complaints of pain; fatigue; or expressions of feelings, attitudes, concerns, goals, and plans. Appropriate, direct quotes are often used in the subjective section of the SOAP note. In this case, it is understood that the statement comes from the individual receiving the therapy, unless otherwise stated. This subjective information will have more significance and relevance to the rest of your note if it specifically pinpoints an issue rather than just noting a vague or general comment from the client. For instance, if the client tells you, “My hand hurts,” you may probe further, asking, “Where does it hurt?” or “When does it hurt?” or “Describe what it feels like.” This will allow your note to communicate more detailed information on the individual’s condition by recording the client’s own description or perception: "Client states he has sharp pain in his Ⓡ thumb and index MP joints when he uses a hammer or wrench." You may quote, paraphrase, or summarize what the client said. Review Chapter 5 for detailed information regarding the use of proper grammar and punctuation for direct and indirect quotes.

Examples of “S” Statements• “I don’t need therapy.” • Student stated she has difficulty changing in and out of her gym clothes within the allotted time in class.• Client reports “pins and needles” in Ⓡ hand when driving >15 minutes.• Client reports feeling frustrated because her short arm cast interferes with ability to perform home management

tasks.• Patient expressed doubts about ever getting better and then began to cry.• Client reports, “I keep losing my patience at home and yelling at my family, and I don’t know what to do about it.”• “I can’t tie my shoes or zip my coat because my thumb is too stiff.”• Veteran reports that he has frequent flashbacks of combat duty that wake him up at night.• Child reports that she is too embarrassed to wear her leg brace and splints because the other students make fun of

her.