What information is recorded in the 'Assessment' section of a SOAP note?

The 'Assessment' section of a SOAP note serves as a crucial component where the clinician synthesizes all the information gathered from the subjective and objective data presented earlier in the note. This section typically includes the healthcare provider's clinical analysis, interpretation of the symptoms, and the evaluation of the patient’s condition. It often integrates observations from the patient's history (subjective data) and the results of physical examinations or tests (objective data) to provide an overall understanding of the health issue being addressed.

This comprehensive analysis allows healthcare providers to convey their clinical judgment and reasoning, ultimately guiding further actions such as treatment options or additional testing necessary for the patient's care.