How do I complete the assessment section of a SOAP note, specifically the problem list?

Structuring the Assessment Section of a SOAP Note

The assessment section should list diagnoses in order of clinical priority based on their impact on morbidity, mortality, and quality of life, starting with the most acute or life-threatening conditions, followed by chronic conditions that require active management, and finally stable chronic conditions. 1, 2

Organizing the Problem List by Priority

Primary Diagnosis First

• List the primary reason for the visit or the most clinically significant active problem at the top of your assessment. 2
• This should be the diagnosis that poses the greatest immediate threat to the patient's health or most significantly impacts their current functional status. 1, 2
• For acute presentations, this means conditions requiring urgent intervention (e.g., acute coronary syndrome, sepsis, diabetic ketoacidosis). 1

Secondary Active Problems

• After the primary diagnosis, list other active medical problems that require intervention or monitoring during this encounter, ordered by their clinical significance. 1, 2
• Include conditions that are uncontrolled or inadequately managed (e.g., "Hypertension - uncontrolled with home BP readings 160/95"). 1
• Document the current status of each problem, including whether it is stable, improving, or worsening since the last visit. 2

Chronic Stable Conditions

• List chronic conditions that are stable and well-controlled after addressing acute and uncontrolled problems. 1
• For each chronic condition, briefly note the control status based on objective evidence (e.g., "Type 2 Diabetes - well controlled, HbA1c 6.8%"). 1

Essential Components for Each Diagnosis

Synthesis of Subjective and Objective Data

• For each diagnosis, demonstrate how you synthesized information from the subjective and objective sections to arrive at that conclusion. 3, 4
• Include your diagnostic reasoning and differential diagnoses considered, especially when the diagnosis is uncertain or when ruling out serious conditions. 3, 5
• Document specific findings that support or refute each diagnosis (e.g., "Pneumonia suspected based on productive cough, fever to 101.5°F, and right lower lobe crackles on exam"). 1, 2

Assessment of Disease Burden

• Document the functional impact of each condition on the patient's quality of life, self-management abilities, and daily activities. 1, 2
• For older adults or those with multiple conditions, note any geriatric syndromes present (cognitive impairment, falls, polypharmacy, depression, urinary incontinence, persistent pain). 1
• Include assessment of the patient's ability to manage their conditions, including any barriers to self-care. 1

Progress Since Last Visit

• For established patients, document changes in each problem since the previous encounter. 2, 5
• Note whether treatments initiated previously have been effective or require modification. 1
• Include relevant monitoring data (home blood pressure readings, blood glucose logs, symptom diaries). 1

Special Considerations

Screening for Comorbid Conditions

• When appropriate, document screening results for conditions commonly associated with the primary diagnosis. 1
• For cancer patients, include assessment of anxiety and depression using validated tools (GAD-7 for anxiety, PHQ-9 for depression). 1, 6
• For patients with diabetes, screen for cognitive impairment annually in those ≥65 years. 1

Interaction Between Problems

• Explicitly note when multiple conditions interact or when treatment of one condition may affect another. 1, 4
• This is particularly important when managing multimorbidity (e.g., "Starting SGLT2 inhibitor will address both heart failure and diabetes while preserving renal function"). 1

Goals of Care

• Include patient-centered goals for each significant problem, particularly for chronic conditions. 1, 3
• Document whether current management aligns with the patient's values and preferences. 1

Common Pitfalls to Avoid

• Do not simply list diagnoses without context - each diagnosis should include supporting evidence and current status. 3, 7
• Avoid documenting physical examination findings in the assessment section - these belong in the objective section; the assessment should interpret those findings. 7, 5
• Do not omit your diagnostic reasoning - especially when considering serious differential diagnoses that were ruled out. 3, 5
• Ensure accuracy - verify that your assessment accurately reflects the documented subjective and objective data. 7