The objective portion of a SOAP note contains which of the following?

Prepare for the ICD-10-CPT Coding Exam. Study with flashcards and multiple choice questions, each backed by elucidative hints and explanations. Ace your certification easily!

The objective portion of a SOAP note is designed to provide measurable and observable data that can be assessed by the healthcare provider. This section includes findings from the physical examination of the patient, such as vital signs, results from diagnostic tests, and observations made by the provider during the evaluation. In contrast to subjective information, which encompasses the patient's symptoms and personal experience of their condition, the objective section relies on factual data that can be quantified and verified.

For example, if a healthcare provider records a patient's blood pressure or examines a rash, these findings would fall under the objective category. This differentiates it from the subjective portion, where the patient's own reports of pain or discomfort would be documented. The objective information is crucial because it provides a foundation for diagnosis and treatment decisions that are not influenced by the patient's perception or emotional response, highlighting its distinct purpose in the healthcare assessment process.

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