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in soap note documentation, what is the pt's documentation goal in the assessment section for the initial evaluation?

User Ytrewq
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Final answer:

The goal in the assessment section of a SOAP note is to synthesize subjective and objective data to form a diagnostic impression and guide the development of a treatment plan.

Step-by-step explanation:

The goal of the patient's documentation in the assessment section of a SOAP note during the initial evaluation is to summarize the patient's health status. This section synthesizes the subjective and objective information collected to form a diagnostic impression or a list of potential diagnoses. The healthcare provider uses clinical reasoning to correlate the patient's symptoms (Subjective data) and the findings from the physical exam, laboratory tests, or imaging (Objective data) to make an assessment. This assessment then guides the development of a treatment plan, which may also include further testing to narrow down the diagnoses.

User Xmojmr
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