A guide to conducting the assessment portion of SOAP notes

A SOAP note is a template tool healthcare clinicians use to capture information consistently while also providing an index to ensure historical details are accessible. As you are probably aware, SOAP is an acronym that represents four different sections of a clinical note. 

• S - Subjective 
• O - Objective 
• A - Assessment 
• P - Plan 

Each section of the SOAP clinical note is integral in ensuring no aspects of the documentation are missed. But of the four quarters, the assessment can be the most difficult as it requires clinical acumen to deduce the data gathered. 

Sounds tricky? 

Not to worry, this article will run you through everything, and if you're still stuck, check out these SOAP note templates too.

What is the general purpose of the assessment part of SOAP notes?

The assessment enables a practitioner to describe and comment on their overall evaluation of a client's condition. This section also acts as a wrap-up of the interaction, with clinicians typically commenting on the patient's overall progress.

‍The assessment part of the SOAP note gives the practitioner the chance to document a synthesis of "subjective" and "objective" evidence to provide a definitive diagnosis. This section assesses the patient's progress through a systematic analysis of the problem, possible interaction, and status changes. It will inform the treatment plan, depending on how the client is engaging or responding to treatment. In addition to this, documentation of the progress or improvements made by the client is essential too. 

In summary, you'll need to include:

1. Diagnoses 
2. Patient progress
3. Changes in medication or treatment

What are some everyday struggles of conducting the assessment portion?

The assessment section can prove to be difficult in some areas; here are some things you'll want to avoid: 

1. Repetition from the subjective and objective observation sections. Remember, if you've noted them above, they don't need to be included here. This section should only include progress, regression, or changes to the treatment plan. Anyone can make an observation, but this is your chance to use those clinical skills to deduce what's going on. 
2. Think about the audience for this documentation. It could be the rest of the care team, just yourself or the client and their family. Remain professional and only include what is relevant. This is true for all SOAP notes sections but is particularly pertinent for the assessment section. 

How to conduct the assessment portion of SOAP notes

To help you avoid these mistakes, here are some significant steps to make sure you'll stay right on track in the assessment section of your SOAP notes: 

Interpret the information given by the client during the session

The client will provide several objective clues and subjective reports of their current state within any session or interaction. This could be a short catch-up over the phone, text, or a longer preliminary assessment with the client. Irrespective of the modality or length of the interaction, you'll have noted down data in the S and O portions of the SOAP note. The assessment part uses these cues and your prior knowledge to interpret what these mean moving forward. This will require applying your clinical knowledge to deduce all the data points and make a conclusion to move forward with a plan. 

Identify the themes and patterns within the information provided

Using the information provided and some historical data, themes and patterns will emerge from the client's presentation, which means you can make a definitive diagnosis and think about the appropriate changes to the current treatment methodology. Individuals develop psychological problems when needs are unfulfilled; therefore, identifying the patterns that may result in psychopathology can assist you in treatment. Identifying themes and patterns within the information is essential for deciding the best course of treatment for each individual. As a clinician, this may take a bit of practice and require a lot of help, supervision, and guidance from more experienced practitioners. If you are unsure, do your homework and seek advice from appropriate sources.  

Update the DSM criteria observations exhibited by the client

After taking the time to interpret the data and deducing the themes or patterns relevant to each client, you'll hopefully be able to paint a clear picture of what will cause the psychopathology the client is experiencing. This means it's time to consult the DSM and define what the client is experiencing. The DSM enables the categorization of psychopathology, allowing the practitioners to dictate the best course of action due to the features of the illness. This website is beneficial in that process, so it's a great place to start if you aren't sure. 

SOAP note assessment examples

Assessment sections of clinical SOAP notes can take a bit of getting used to. Hopefully, this article has helped to clarify what's required. In addition to this, we also have created some SOAP note examples for different disciplines that will mean you can see what the end goal might be. 

Here's a link to our SOAP notes examples and templates