In SOAP notes, which component records the clinician's assessment based on the collected data?

• A. Subjective
• B. Objective
• C. Assessment
• D. Plan

Answer: (C)

The main idea being tested is how a clinician interprets all collected information to form a clinical impression. The section that records this synthesis is the Assessment. It takes what the patient reports (Subjective) and what’s observed or measured (Objective) and translates that into a diagnosis or problem list, along with the reasoning, potential etiologies, and possibly a differential diagnosis. This is different from the Subjective portion, which captures patient-reported symptoms; the Objective portion, which lists measurable findings; and the Plan, which outlines the next steps, treatments, and follow-up. For example, after considering symptoms like fever and cough plus exam findings, the Assessment might state an impression of acute bronchitis with pneumonia as a differential, guiding the subsequent Plan.