In the SOAP note, what does the Assessment section typically include?

• A. Clinical impression/diagnosis
• B. Interventions and goals
• C. Subjective history
• D. Plan of care and follow-up

Answer: (A)

Assessment is where you present the clinician’s conclusion after reviewing what the patient reports and what you find on examination. It includes the clinical impression or diagnosis, notes on the current severity and functional impact, and any differential considerations with justification for the chosen conclusion. This section ties the subjective and objective data together into a concise conclusion that guides the next steps. Interventions and goals belong in the Plan, not in the Assessment, and the subjective history sits in the Subjective section, with the plan of care and follow-up documented in the Plan.