GAUTHAM COLLEGE OF PHARMACY

The assessment (A) section outlines what the practitioner thinks the patient’s problem is, based upon the subjective and objective Information acquired. This assessment often takes the form of a diagnosis or differential diagnosis. This portion of the SOAP note should include all of the reasons for the clinician’s assessment. This helps other health care providers reading the note to understand how the clinician arrived at his or her particular assessment of the problem.

 

 

This is potentially the most important legal note because this is the therapists professional opinion in light of the subjective and objective findings. It should explain the reasoning behind the decisions taken and clarify and support the analytical thinking behind the problem-solving process. Progress towards the stated goals are indicated, as well as any factors affecting it that may require modification of the frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

 

A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including adifferential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options. When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment.

 

Common errors:

 

• The assessment is too vague e.g. "Patient is improving".

• Little insight is provided.