Which element is included in the 'O' section of the SOAP note?

• A. History of Present Illness (HPI)
• B. Physical Examination (PE)
• C. Diagnosis
• D. Plan

Answer: (B)

The 'O' section of the SOAP note refers to the "Objective" part, which includes the physical examination findings and any observable data collected during the patient encounter. This section is critical because it provides measurable, quantifiable information that can be observed or tested, contrasting the subjective information documented in the 'S' (Subjective) section.

Thus, the inclusion of the Physical Examination in the 'O' section is essential for forming a comprehensive understanding of the patient's condition. It informs clinical decisions and helps in planning further diagnostic or therapeutic interventions based on objective data. This can include vital signs, results from physical assessments, laboratory findings, and imaging studies, all contributing valuable insights into the patient's health status.