In which section of a medical note would you find a diagnosis?

The diagnosis in a medical note is typically found in the Assessment section. This section is crucial as it synthesizes the information gathered in the Subjective and Objective sections, allowing healthcare providers to formulate a clinical judgment based on the patient's reported symptoms and the findings from their examination. The Assessment reflects the provider's interpretation of the data and includes the diagnosis or diagnoses determined from that analysis.

Understanding the framework of a medical note can clarify why the Assessment section is the most appropriate for locating the diagnosis. The Subjective section captures the patient's complaints and history, while the Objective section contains measurable findings from examinations and tests. The Plan section outlines the proposed management strategies or interventions based on the diagnosis established in the Assessment. Thus, the Assessment section serves as the critical juncture where the diagnosis is made explicit.