What does the term "Assessment" refer to in the SOAP format?

In the SOAP format, "Assessment" refers to the healthcare provider's understanding of what is wrong with the patient based on the information gathered through observations and evaluations. This component connects the subjective information reported by the patient and the objective findings noted by the provider. It synthesizes these details into a clinical impression or diagnosis, allowing the healthcare team to formulate a structured approach to care.

The assessment is essential because it reflects the clinician's clinical reasoning, evaluating the findings and determining how they correspond to potential diagnoses. By doing so, it lays the groundwork for future steps in patient management, including the treatment plan.

Other aspects, like medical history or severity of symptoms, contribute to the background information but do not encapsulate the analytical process involved in deriving a diagnosis from the collected data. The treatment plan constitutes the actions to be taken but is a subsequent step that follows the assessment of the patient's condition.