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What does the assessment portion of SOAP consist of?

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Final answer:

In the SOAP format, the assessment section is the healthcare professional's evaluation that synthesizes the subjective and objective information to form a differential diagnosis and supports clinical decision-making.

Step-by-step explanation:

The assessment portion of the SOAP (Subjective, Objective, Assessment, Plan) format includes the healthcare professional's evaluation of the patient's current condition based on the subjective and objective data collected. In practice, this section often synthesizes the information from the 'Subjective' history given by the patient, with the 'Objective' findings from the physical exam, laboratory results, and imaging studies to formulate a list of possible diagnoses or issues. This is followed by a differential diagnosis where the most likely diagnosis is determined based on the evidence. It may also include an interpretation of the findings in the context of the patient's history and clinical presentation. The goal of the assessment is to organize the collected information in a way that supports clinical decision-making and planning for the patient's care.

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