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Assessment: The next section of a SOAP note is assessment. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong.

Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections.

Subjective What the Patient Tells you. This section refers to information verbally expressed by the patient. Objective What You See. This section consists of observations made by the clinician. Assessment What You Think is Going on. Plan What You Will Do About It.

Components. The four components of a SOAP note are Subjective, Objective, Assessment, and Plan.

O: Objective This section is where you document measurable outcomes about your client's performance, including test scores, percentages for any goals worked on, and other quantitative information.

Today, the SOAP note an acronym for Subjective, Objective, Assessment and Plan is the most common method of documentation used by providers to input notes into patients' medical records. They allow providers to record and share information in a universal, systematic and easy to read format.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the subjective experiences, personal views or feelings of a patient or someone close to them.