What should the assessment section in a SOAP (Subjective, Objective, Assessment, Plan) example include?

Assessment Section in SOAP Documentation

The assessment section of a SOAP note should include a clear synthesis of the patient's problems, differential diagnoses, and clinical reasoning that connects subjective and objective findings to formulate a diagnostic conclusion and severity assessment.

Core Components of the Assessment Section

Problem Identification and Diagnosis

• Clearly list all identified problems in order of priority 1
• State the primary diagnosis or most likely diagnosis for each problem 2
• Include relevant differential diagnoses that were considered 1
• Specify the severity or stage of each condition when applicable 1

Clinical Reasoning

• Synthesize subjective and objective data to support your diagnostic conclusions 2
• Explain your rationale for arriving at specific diagnoses 1
• Document how you ruled in or ruled out alternative diagnoses 1
• Include pertinent positive and negative findings that influenced your assessment 1

Risk Assessment

• Evaluate the patient's risk factors for morbidity and mortality 1
• Document any factors that might affect prognosis 1
• Assess the impact of comorbidities on the current condition 3
• Include functional status assessment when relevant 3

Specialized Assessment Elements

Quality of Life Impact

• Document how the condition affects the patient's daily functioning 3
• Assess impact on physical and functional wellbeing 3
• Note effects on the patient's ability to perform important activities 3

Pain Assessment (When Applicable)

• Document pain characteristics including severity, type, and quality 3
• Assess the impact of pain on function and quality of life 3
• Include assessment of sleep problems related to the condition 3

Nutritional Assessment (When Applicable)

• Include relevant nutritional status evaluation 3
• Document any nutrition-related concerns that impact the condition 3

Common Pitfalls to Avoid

Incomplete Assessment

• Failing to address all identified problems
• Not documenting clinical reasoning behind diagnoses
• Omitting severity or staging information

Poor Organization

• Mixing assessment with plan elements
• Not prioritizing problems by clinical importance
• Including raw data that belongs in the objective section

Inadequate Synthesis

• Simply restating subjective and objective findings without interpretation
• Not connecting findings to diagnostic conclusions
• Failing to document differential diagnoses for unclear presentations

Documentation Best Practices

• Use clear, concise language that avoids ambiguity 1
• Number or bullet problems for clarity and organization
• Document using standardized formats in electronic medical records 1
• Ensure assessment reflects current evidence-based diagnostic criteria 1
• Include assessment of response to previous treatments for follow-up visits

By following these guidelines, the assessment section will effectively bridge the gap between the collected data (subjective and objective sections) and the treatment decisions (plan section), providing a clear record of clinical reasoning and diagnostic conclusions.