What information is typically found in the Assessment section of SOAP notes?

The Assessment section of SOAP notes is specifically designed to summarize the clinician's evaluation of the client's condition based on the subjective and objective data collected. This is where the healthcare provider synthesizes the information gathered and provides a clinical assessment. The physician's medical diagnosis is a crucial component of this evaluation because it reflects the clinician's professional judgment about the client's condition and helps guide further treatment and intervention strategies.

Including the medical diagnosis in the Assessment section allows for continuity of care and informs other professionals involved in the client’s treatment about the underlying health concerns that need to be addressed. This also aids in setting appropriate goals and determining the effectiveness of therapeutic interventions.

The other options, while important in their respective places, do not belong in the Assessment part of SOAP notes. Treatment recommendations would typically be found in the Plan section, a list of referrals might be logged under the Plan or as part of the Objective findings, and the client's main complaint would be documented in the Subjective section to capture the client's own words regarding their issues.