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What is an example of what might be recorded in the subjective part of a SOAP note?

1) Client will be educated on stress-management techniques, and with support will develop a SMART goal focused on stress management
2) Weight: 210 pounds (weight gain of 4 pounds)
3) Client's stress has caused overeating and weight gain
4) Client stated he was stressed over work during the last week, which caused him "to drink a lot of beer and watch TV"

1 Answer

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Final answer:

The subjective part of a SOAP note includes the patient's reported symptoms, feelings, and experiences.

Step-by-step explanation:

Examples of what might be recorded in the subjective part of a SOAP note include:

  1. Client stated he was stressed over work during the last week, which caused him 'to drink a lot of beer and watch TV'
  2. Client's stress has caused overeating and weight gain

The subjective part of a SOAP note includes the patient's reported symptoms, feelings, and experiences. It provides subjective information that cannot be clinically confirmed or objectively measured, but it is important for understanding the patient's perspective and overall health.

An example of what might be recorded in the subjective part of a SOAP note is option 4) Client stated he was stressed over work during the last week, which caused him "to drink a lot of beer and watch TV". The subjective section of the SOAP note includes what the client expresses in their own words regarding their experience, which in this case includes their feelings, thoughts, and personal experiences related to stress. It forms a crucial part of understanding the individual's perception of their health and well-being.

Symptoms such as stress are subjective experiences that cannot be measured as precisely as objective signs, such as weight. Clinicians may attempt to quantify symptoms through scales like the Wong-Baker Faces pain-rating scale or by measuring physiological responses like skin conductance. Understanding subjective experiences, such as increased stress leading to weight gain and overeating, as reported in patient B, is vital for thorough patient assessment and care planning.

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