How do I write a high-quality assessment statement that summarizes a patient's history, physical examination, and laboratory results in the assessment/plan part of the SOAP (Subjective, Objective, Assessment, and Plan) note?

Writing a High-Quality Assessment Statement in SOAP Notes

The assessment statement should be a concise, problem-oriented synthesis that integrates pertinent positive and negative findings from the history, physical examination, and diagnostic results into a prioritized differential diagnosis or working diagnosis, with each problem explicitly linked to supporting clinical data. 1

Core Components of the Assessment Statement

Structure and Content Requirements

The assessment must document specific clinical findings that directly support your diagnostic reasoning, not generic statements 1. Include:

• Primary diagnosis or working diagnosis with severity indicators (e.g., "acute exacerbation," "stable," "worsening") 1
• Pertinent positive findings from history (symptom chronology, quality, intensity, distribution, duration, sensory and affective components) 1
• Pertinent negative findings that rule out competing diagnoses 1
• Objective data integration including vital signs, physical examination findings (cardiopulmonary assessment, neurologic evaluation, musculoskeletal findings), and laboratory/imaging results 1
• Functional impact on activities of daily living and quality of life 1

Disease-Specific Assessment Elements

For cardiovascular conditions, document left ventricular function, comorbidities (peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, diabetes), medication compliance, and cardiovascular risk profile 1. For peripheral artery disease specifically, include exertional leg symptoms, claudication characteristics, ischemic rest pain, nonhealing wounds, and pulse examination findings (femoral, popliteal, dorsalis pedis, posterior tibial) 1.

For obesity-related assessments, document BMI with ethnic-specific considerations, waist circumference, drivers of weight gain (medical conditions, medications, metabolism, dietary habits, sleep patterns, sedentary lifestyle), psychological factors (stress, anxiety, eating disorders, depression), and obesity-related complications across body systems 1.

For chronic pain, the assessment must include pain chronology, quality, intensity, distribution, duration, sensory and affective components, motor/sensory/autonomic changes, physical deconditioning, occupational status changes, psychosocial dysfunction, and impacts of previous treatments 1.

Writing the Assessment Statement

Problem-Based Organization

List each problem separately with supporting data immediately following each diagnosis 1. For example:

• Problem #1: Acute coronary syndrome - supported by substernal chest pain radiating to left arm, diaphoresis, ST-segment elevation in leads II, III, aVF on ECG, elevated troponin I at 5.2 ng/mL 1
• Problem #2: Type 2 diabetes mellitus, poorly controlled - HbA1c 9.2%, fasting glucose 210 mg/dL, patient reports medication non-adherence 1

Integration of Clinical Data

The assessment should synthesize findings across domains 1:

• History elements: onset, quality, intensity, distribution, duration, course of symptoms; previous diagnostic tests and therapies; current medications; substance use; family history 1
• Physical examination: vital signs (pulse rate/regularity, blood pressure), system-specific findings (cardiopulmonary auscultation, edema, pulse palpation, neurologic evaluation, musculoskeletal assessment) 1
• Laboratory/diagnostic results: ECG findings, laboratory values with reference ranges, imaging results 1
• Psychosocial factors: impact on mood, sleep, interpersonal relationships, functional abilities, family/vocational/legal issues 1

Severity and Prognostic Indicators

Include quantifiable measures of disease severity and functional status 1:

• Functional capacity in METs or VO2 for cardiac patients 1
• Neurological outcome scores (Cerebral Performance Category, modified Rankin Scale) when applicable 1
• Quality of life assessments using validated instruments 1
• Depression screening results (CES-D, Geriatric Depression Scale) 1
• Functional assessment scores (Pfeffer Functional Assessment Questionnaire, Barthel Index) 1

Common Pitfalls to Avoid

Never write vague statements like "patient presents with chest pain" without specifying character, radiation, timing, associated symptoms, and objective correlates 1. Avoid listing diagnoses without supporting clinical data 1.

Do not simply restate the subjective and objective sections - the assessment synthesizes this information into diagnostic reasoning 1. Each diagnosis must be justified by specific findings 1.

Always document the impact on function and quality of life, not just the disease diagnosis 1. This includes effects on activities of daily living, occupational status, and psychosocial well-being 1.

Specify timing and context for all findings (e.g., "symptoms began 2 hours ago at rest" rather than "chest pain present") 1. Include the temporal relationship between symptoms and objective findings 1.