When examining a patient the advanced practice registered nurse (APRN) notices a 3 cm x 2 cm indurated erythematous mass in the right axilla. In which area of the SOAP note should this information be documented?

A. Subjective is incorrect because subjective data consists of information provided directly by the patient, including symptoms, complaints, feelings, or personal reports (e.g., “I have pain in my armpit”). While the patient may have mentioned discomfort, the APRNs observation of the mass itself is not subjective. B. Objective is correct because the 3 cm x 2 cm indurated erythematous mass is a measurable, observable finding identified during the physical examination. Objective data includes all information that can be quantified, observed, or measured by the clinician, such as vital signs, laboratory values, imaging results, physical exam findings, and documented lesions or masses. The APRN’s observation of size, location, consistency, and color of the mass fits perfectly in the objective category of the SOAP note. This ensures that there is an accurate, factual record of the patient’s physical status for follow-up, diagnostic evaluation, and treatment planning. C. Assessment is incorrect because this section is reserved for the clinician’s interpretation or diagnostic impression based on both subjective and objective data. For example, after observing the mass, the APRN might write “Possible axillary abscess” or “Enlarged lymph node requiring further evaluation.” The assessment is not the initial observation itself. D. Plan is incorrect because the plan details the next steps for management, such as ordering tests, prescribing medication, referring to a specialist, or planning follow-up. Documenting the mass itself in the plan section would be inappropriate, as it is not an action or intervention.