What is a key element of the assessment phase in the SOAP note framework?

The assessment phase of the SOAP note framework is focused on providing an overall clinical impression of the patient's condition. This involves synthesizing the information gathered during the subjective and objective phases to formulate a diagnosis or clinical evaluation based on the data available. The clinician uses their expertise to interpret the patient’s symptoms, medical history, and findings from physical examinations or diagnostic tests, allowing them to make informed decisions regarding the patient's care.

In contrast, identifying diagnostic codes is typically performed in the coding and billing process rather than within the clinical judgment of the assessment phase. Recording patient complaints is part of the subjective documentation that occurs in the initial phase of a SOAP note, where the clinician listens to the patient’s expressed concerns and symptoms. While external referrals may be necessary depending on a patient’s condition, they do not form a part of the assessment itself; they are a subsequent action based on the assessment made.