A guide to conducting the assessment portion of SOAP notes

What is a SOAP note?

A SOAP note template is a tool that healthcare clinicians use to capture information consistently while providing an index to ensure that historical details, such as family history or surgical history, are accessible. As you probably know, SOAP is an acronym representing four different sections of a clinical note referring to subjective, objective, assessment, and plan.

Each section of the SOAP clinical note is integral in ensuring no aspects of the documentation are missed. However, of the four quarters, the assessment in SOAP notes can be the most difficult as it requires clinical acumen and clinical reasoning to deduce the data gathered during a patient encounter.

Sounds tricky? 

Not to worry—this article will walk you through everything. If you're still stuck, you can check out these SOAP note templates, too.

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

The assessment in SOAP note section enables a practitioner to describe and comment on their overall evaluation of a client's condition. So, what goes in the assessment part of a SOAP note?

This section is a wrap-up of the interaction, with clinicians typically commenting on the patient's progress. This then includes how would the patient describe their symptoms and experiences.

The assessment part of the SOAP note gives the practitioner the chance to document a synthesis of "subjective" and "objective" evidence, such as laboratory tests, to provide a definitive differential diagnosis. This section assesses the patient's progress through a systematic analysis of the problem, possible interactions, and status changes.

How the client is engaging or responding to treatment will inform the treatment plan. In addition, documentation of the client's progress or improvements, including changes in the patient's status, is essential.

In summary, you'll need to include:

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

Challenges in 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 sections: Remember, if you've noted the client's chief complaint or objective information 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 happening.
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 when you write SOAP notes, particularly in the assessment section:

Interpret the information given by the client during the session

The client will provide several objective clues and subjective reports of their current state during sessions or interactions. 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 subjective and objective sections of the SOAP note. The assessment part uses these cues and prior knowledge to interpret what the patient described during the session, applying your clinical reasoning 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. This means you can make a definitive differential diagnosis and consider 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 that the client reported 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 some getting used to. Hopefully, this article has helped clarify what's required. We have also created SOAP note examples for different disciplines that will allow you to see the end goal. 

Chronic back pain

Assessment:

The patient has had chronic lower back pain for the past six months. Based on the patient's age, history of prolonged sitting, and physical examination findings (tenderness in the lumbar region, reduced range of motion), the most likely diagnosis is lumbar strain. Differential diagnoses include lumbar disc herniation and facet joint syndrome. Imaging studies may be considered if symptoms persist or worsen.

Hypertension follow-up

Assessment:

The patient is a 50-year-old male with a known history of hypertension, currently on lisinopril 20 mg daily. Today's blood pressure reading is 145/90 mmHg, indicating suboptimal control. The patient reports adherence to the medication regimen but admits to a high-sodium diet. The assessment is poorly controlled hypertension, likely due to dietary non-compliance. Recommendations include dietary modifications and consideration of adding a diuretic if blood pressure remains elevated on follow-up.

Upper respiratory infection (URI)

Assessment:

The patient is a 25-year-old female presenting with a three-day history of sore throat, nasal congestion, and mild fever. Examination reveals erythematous pharynx without exudates and clear lung sounds. Based on clinical findings and the absence of significant systemic symptoms, the most likely diagnosis is a viral upper respiratory infection. Bacterial infection is less likely, given the absence of purulent sputum or significant lymphadenopathy. Symptomatic treatment and supportive care are advised.

Check out more examples of SOAP notes that also include the subjective, objective, and plan sections.

Final thoughts

SOAP notes' assessment portion is an essential component that shows a clinician's ability to synthesize information and apply clinical reasoning. While challenges like avoiding repetition and maintaining professionalism exist, mastering this can enhance comprehensive patient care. With practice and guidance, clinicians can develop the skills necessary to create thorough and insightful assessments, ultimately leading to better patient outcomes and more effective healthcare delivery.