Which section of SOAP notes would include vital signs and lab tests?

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The section of SOAP notes that includes vital signs and lab tests is the Objective section. This part of the SOAP note is dedicated to observable and measurable data that is gathered during the assessment of the client. Vital signs, such as heart rate, blood pressure, temperature, and respiratory rate, are quantifiable measurements that provide essential information about the client’s physical health. Similarly, lab tests yield numerical values and outcomes that can be documented to inform the client's overall condition and inform clinical decisions.

In contrast, the Subjective section is reserved for the client's personal experiences, feelings, and descriptions of symptoms, which are not objectively measurable. The Assessment section synthesizes the information and provides the clinician’s interpretation or diagnosis based on the subjective and objective data. Lastly, the Plan section outlines the proposed interventions based on the assessment findings and the goals to be achieved. Understanding where to place various types of information in SOAP notes is crucial for effective documentation and communication within a therapeutic setting.

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