What information would you find in the Assessment section of a SOAP note?

The Assessment section of a SOAP note is crucial for summarizing the clinician's clinical reasoning and identifying the problems related to the patient's condition. It typically includes the synthesis of the information gathered during the Subjective and Objective sections and translates that information into the clinician’s interpretation of the situation. This encompasses diagnosing any issues, noting underlying problems, and defining the patient's current health status.

This section provides a rationale for the clinical decisions being made, highlighting significant findings that impact patient management, and may identify goals or potential outcomes. This is essential in clinical practice as it guides future interventions and the overall treatment plan for the patient. The other options pertain to different sections of the SOAP note, with Measurable data typically found in the Objective section, Interventions planned being part of the Plan section, and Frequency and duration also associated with the Plan or the treatment protocols.