What is a proper template for the Objective (O) section in a SOAP note?

Template for the Objective (O) Section in SOAP Notes

The Objective section should systematically document vital signs, physical examination findings relevant to the patient's condition, and all measurable data including laboratory values and diagnostic test results. 1

Core Components to Include

Vital Signs (Required)

Document all of the following measurements: 1

• Heart rate
• Blood pressure
• Respiratory rate
• Room air oxygen saturation
• Temperature

Physical Examination Findings

Record only examination findings that are directly relevant to the patient's presenting condition. 1 This should be focused and problem-oriented rather than a comprehensive review of all systems. 2

Laboratory and Diagnostic Data

Include all measurable, objective data: 1

• Laboratory test results with specific values
• Imaging study findings
• Diagnostic test results (e.g., ECG, spirometry)
• Any other quantifiable clinical measurements

Documentation Principles

What NOT to Include

Do not document subjective symptoms in the Objective section. 3 A common error is placing patient-reported symptoms (which belong in Subjective) under Objective—only 27.4% of medical students correctly avoided this mistake in one assessment. 3

Accuracy and Completeness

• Document only findings that were actually observed or measured during the encounter 3
• Record physical examination findings that were performed, not assumed 3
• Ensure all documented information is factual and objective 1

Organization and Clarity

• Use a systematic approach to avoid overlooking important elements 1
• Keep documentation simple, straightforward, and comprehensible 1
• Use appropriate formatting to ensure legibility 1

Common Pitfalls to Avoid

The most significant documentation error is inappropriate recording of physical examinations—only 9.5% of students documented physical findings accurately in one study. 3 Specifically:

• Do not document examinations that were not performed 3
• Do not include patient's subjective complaints in this section 3
• Do not omit vital signs or measurable data that were obtained 1

Quality Assurance

• Review notes for errors before finalizing 1
• Verify that all information is factual and objective 1
• Ensure completeness by checking that all relevant objective data are included 1