Structure Subjective, Objective, Assessment, and Plan are the four headings of a SOAP note. Each heading is explained more below. Subjective This is the SOAP note's first heading. Documentation under this topic is based on a patient's or someone close to them's "subjective" experiences, personal perspectives, or feelings. Interim information is included in the inpatient setting. This section sets the stage for the Assessment and Plan. Complaint in Chief (CC) The patient reports the CC or presenting condition. This can be a symptom, a condition, a previous diagnosis, or another brief description of why the patient is appearing now. The CC is comparable to a paper's title in that it gives the reader an idea of what the rest of the document will include. Examples include chest pain, loss of appetite, and shortness of breath. However, a patient may have numerous CCs, and the initial one may not be the most serious. As a result, clinicians should encourage patients to express all of their concerns while paying close attention to detail in order to identify the most compelling condition. To execute an effective and efficient diagnosis, the primary problem must be identified. Present Illness History (HPI) The HPI starts with a one-line opening statement that includes the patient's age, gender, and reason for the appointment.