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The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.

Writing a SOAP NoteSelf-report of the patient.Details of the specific intervention provided.Equipment used.Changes in patient status.Complications or adverse reactions.Factors that change the intervention.Progression towards stated goals.Communication with other providers of care, the patient and their family.

Assessment & PlanWrite an effective problem statement.Write out a detailed list of problems. From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.Combine problems.

Subjective What the Patient Tells youTake note of the patient 's complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes.

The SOAP format Subjective, Objective, Assessment, Plan is a commonly used approach to. documenting clinical progress.

A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction.However, all SOAP notes should include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan.S = Subjective or symptoms and reflects the history and interval history of the condition. The patient's presenting complaints should be described in some detail in the notes of each and every office visit.