Which component in SOAP notes contains the clinician's diagnosis or impression?

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

Answer: (B)

In SOAP notes, the section that contains the clinician's diagnosis or impression is the Assessment. This part breathes meaning into what was gathered: the subjective information from the patient (what they report about their symptoms and history) and the objective data from the exam, tests, and observations are synthesized to form the clinician’s interpretation. The assessment may present the final diagnosis if available, or a prioritized differential diagnosis if the diagnosis isn’t yet certain, sometimes with notes on reasoning, severity, prognosis, or contributing factors. The Plan section follows, detailing the treatment steps, orders, referrals, and patient education needed to address the diagnosis. The Subjective and Objective sections, in contrast, provide the raw data the clinician uses to reach that assessment.