SOAP Notes – Subjective Section Overview

The Subjective section is the first portion of the SOAP note and is completed at the beginning of each appointment. It captures the patient's perspective on their condition, including pain levels, progress, and how the issue affects daily life. The structure of this section varies depending on whether it's the first appointment or a follow-up.

📍 1st Appointment – Initial Subjective Intake

At the initial visit of a referral, the Subjective section focuses on understanding the patient’s injury or condition, its impact on daily activities, and their overall pain experience.

✅ Required Actions:

• Ask detailed questions about the condition being treated and its functional impact.

• Complete the Global Pain Scale (GPS) questionnaire.

🧠 Notes on GPS:

• Used at:

  • 1st appointment

  • Midpoint appointment

  • Appointment prior to additional services request (typically 1–2 visits before the final session)

• This longer scale captures comprehensive pain-related data to:

  • Track patient progress over time

  • Provide evidence for requests for continued care

⚠️ Important:

• After submission, you can edit:

  • Your free-text Subjective responses

• You cannot edit:

  • Responses to the Global Pain Scale once submitted

• Double-check pain scale responses before saving and submitting.

🔁 2nd Appointment & Subsequent Visits

Starting from the second appointment onward, the Subjective section focuses on progress and changes since the previous session.

✅ Required Actions:

• Ask about:

  • Post-treatment effects

  • Changes in pain levels

  • Improvements or limitations in daily activities

• Complete the Defense and Veterans Pain Rating Scale (DVPRS).

🧠 Notes on DVPRS:

• A shorter pain assessment tool used for:

  • 2nd appointment

  • All standard follow-ups except those requiring GPS

⚠️ Important:

• You may edit free-text responses after submission.

• You cannot edit DVPRS answers once submitted.

• Ensure all answers are reviewed carefully before saving.

❓ Need Help?

If you experience technical issues or have questions about pain scales, SOAP note formatting, or when to use GPS vs. DVPRS, contact your team lead or reach out through the provider support channel.