Question

A medical assistant is reviewing the progress notes of a patient's record that uses the SOAP format. Which of the following would the medical assistant find in the assessment section?

1) Subjective information from the patient
2) Objective findings from physical examination
3) Diagnoses or assessment of the patient's condition
4) Plan for further treatment or management

Answer 1

In the SOAP format, the Assessment section contains the healthcare provider's diagnoses or evaluation of the patient's condition, based on subjective and objective information.

Step-by-step explanation:

In the SOAP (Subjective, Objective, Assessment, and Plan) format commonly used in medical documentation, the Assessment section would contain the healthcare provider's diagnoses or evaluation of the patient's condition. This is after they have listed subjective information from the patient’s own experiences and objective findings from physical examinations or diagnostic tests.

For instance, the provider might note an assessment such as 'possible migraine' after reviewing the patient's subjective complaint of a severe headache and objective findings such as lack of neurological deficits. The assessment leads to the next step, which is the Plan for further treatment or ongoing management of the patient's health issue.