Read the language of care

Medical Record Sections

Locate history, reported symptoms, examination findings, and plans.

What to know

Use section headings to locate details in a record. In a SOAP note, the letters stand for Subjective, Objective, Assessment, and Plan. Keep reported observations distinct from measured findings.

LESSONQuestion 1 of 6

Multiple choice

Which section typically records why the person came for the visit?

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Question ID tp-d1731bc6. Debug mode is active and email delivery is disabled. Leave personal and patient information out of notes.