In a SOAP note, what goes in the Assessment section?

In a SOAP note, what goes in the Assessment section?

• A. The patient’s vital signs and exam findings
• B. The diagnoses or differential diagnoses and the clinician’s impression
• C. The plan of care and follow-up instructions
• D. The patient’s medical history

Answer: (B)

In the Assessment, you synthesize what the data mean for the patient’s problem. It’s where you put the diagnoses or differential diagnoses and your clinical impression based on the history, exam, and any tests. You explain why you think a certain condition fits the presentation and you may prioritize the possibilities by likelihood, sometimes noting any uncertainties or alternative explanations. This is the part that connects what was observed and tested to what you believe is happening. Vital signs and exam findings belong in the Objective portion, not the Assessment. The plan of care and follow-up instructions belong in the Plan. The patient’s medical history is part of the subjective information you gathered.

In the Assessment, you synthesize what the data mean for the patient’s problem. It’s where you put the diagnoses or differential diagnoses and your clinical impression based on the history, exam, and any tests. You explain why you think a certain condition fits the presentation and you may prioritize the possibilities by likelihood, sometimes noting any uncertainties or alternative explanations. This is the part that connects what was observed and tested to what you believe is happening.

Vital signs and exam findings belong in the Objective portion, not the Assessment. The plan of care and follow-up instructions belong in the Plan. The patient’s medical history is part of the subjective information you gathered.