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The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections. Summarise the salient points: ?Productive cough (green sputum)? ?Increasing shortness of breath?

SOAP?or subjective, objective, assessment and plan?notes allow clinicians to document continuing patient encounters in a structured way.

Introduction. The Objective (O) part of the note is the section where the results of tests and measures performed and the therapist's objective observations of the patient are recorded. Objective data are the measurable or observable pieces of information used to formulate the Plan of Care.

An example of this is a patient stating he has ?stomach pain,? which is a symptom, documented under the subjective heading. Versus ?abdominal tenderness to palpation,? an objective sign documented under the objective heading.

ubjective The section is the place to report anything the client says or feels that is relevant to their session or case. This includes any report of limitations, concerns, and problems.

Subjective - What the patient says about the problem / intervention. Objective - The therapists objective observations and treatment interventions. (e.g. ROM, Outcome Measures) Assessment - The therapists analysis of the various components of the assessment.

Introduction. The Objective (O) part of the note is the section where the results of tests and measures performed and the therapist's objective observations of the patient are recorded. Objective data are the measurable or observable pieces of information used to formulate the Plan of Care.