Case Study 2: Assessment

After reviewing your objective findings list your Assessment or diagnoses for the key findings. This is the 'A' part of the SOAP note format.

This is often best done by following a standardised format for beginning students. For example:

• write about the presenting complaint, then
• dermatological, orthopaedic/ musculoskeletal, neurological, vascular, footwear and other assessments.

Sometimes students can confuse objective examination findings such as neurological assessment with the 'A' part of the SOAP notes.

The difference is the 'A' part of the SOAP notes contains your conclusions or your diagnosis based on the test results, not the test results themselves.

When you have written your notes, look at the staff notes in the file on the next page.