<Li> Findings from physical examinations, including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities . </Li> <Li> Results from laboratory and other diagnostic tests already completed . </Li> <P> A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms / diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely . The assessment will also include possible and likely etiologies of the patient's problem . It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective . In a pharmacist's SOAP note, the assessment will identify what the drug related / induced problem is likely to be and the reasoning / evidence behind it . This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options . When used in a Problem Oriented Medical Record, relevant problem numbers or headings are included as subheadings in the assessment . </P> <P> The plan is what the health care provider will do to treat the patient's concerns - such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided . The plan will also include goals of therapy and patient - specific drug and disease - state monitoring parameters . This should address each item of the differential diagnosis . For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy . A note of what was discussed or advised with the patient as well as timings for further review or follow - up are generally included . </P>

Where does diagnosis go in a soap note