Explain the SOAP note format and what belongs in each section.

• A. Subjective: imaging results; Objective: ROM.
• B. Subjective: symptoms/history; Objective: ROM, strength; Assessment: diagnosis; Plan: therapy.
• C. Subjective: patient-reported symptoms/history; Objective: ROM, strength; Assessment: clinical impression/differential; Plan: treatment, referrals, imaging, and follow-up.
• D. Subjective: patient-reported symptoms/history; Objective: ROM, strength; Assessment: clinical impression/differential; Plan: treatment, referrals, imaging, and follow-up.

Answer: (C)

SOAP notes are built to tell the patient story in a clear, organized way: what the patient reports, what you observe and measure, how you interpret those findings, and what you plan to do next. The Subjective portion should capture patient-reported symptoms and history, focusing on what the patient experiences, including onset, duration, quality, severity, and factors that worsen or relieve symptoms. The Objective portion lists measurable or observable data you gather during the exam—things like range of motion and strength tests, as well as any imaging or physical findings obtained during assessment. The Assessment is your clinical impression, which often includes a differential diagnosis—the range of likely causes based on the subjective and objective data—and a statement about the severity or prognosis. Finally, the Plan lays out the next steps: treatments or therapies, any referrals, orders for imaging if needed, and the plan for follow-up. In this context, the best answer reflects those four elements with the plan explicitly including treatment, referrals, imaging, and follow-up, and the assessment noting both the clinical impression and differential.