The objective portion of a SOAP note includes which elements?

• A. Visual Inspection, Palpation, Range of Motion, Manual Muscle Tests, and Special Tests
• B. History
• C. Diagnosis
• D. Plan

Answer: (A)

During the examination, the objective portion captures what the clinician directly observes and measures. Visual inspection records visible signs such as swelling, deformity, and gait abnormalities. Palpation notes tenderness, warmth, effusion, and tissue texture. Range of motion documents how much the joint can move actively and passively, along with any limitations. Manual muscle testing provides a strength grade for the surrounding muscles. Special tests use targeted maneuvers to provoke symptoms or signs and help confirm a diagnosis, with results noted as positive, negative, or with a specific finding. These findings are objective because they come from the examiner’s direct observation and measurement, not from the patient’s description. The subjective portion would include the patient’s history and reported symptoms, the assessment is the clinician’s diagnosis or impression, and the plan details treatment, referrals, and follow-up.