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December 1992

SOAP Is Good for Medical Record

Author Affiliations

Rochester, NY

Arch Intern Med. 1992;152(12):2511. doi:10.1001/archinte.1992.00400240121027

To the Editor.—  I think it is admirable that the authors of the article on SOAP notes for the medical record1 believe that the S portion or the subjective portion of that designation should be changed to something like H for history. I believe that whether we call this S portion subjective, symptoms, or history is merely a matter of semantics.All good clinicians know that the history or subjective portion of patient examination provides the most important data for arriving at a correct diagnosis, leading one to examine appropriate areas of the body and decide on what appropriate testing is required to arrive at a correct answer. I agree that the exact narrative of the patient should be captured by careful listening with as little observer interview interruption as possible.This narrative should be captured in the patient's own words and even though this is subjective on the