SoapLab - Clinical Documentation Training

The Assessment Section

The Assessment is the heart of your clinical reasoning. It's where you synthesize the subjective and objective data into a coherent clinical picture. A strong assessment demonstrates your critical thinking, supports your plan, and guides other providers who may care for the patient.

Components of a Strong Assessment

A complete assessment includes:

•Primary/working diagnosis with supporting evidence
•Differential diagnoses ranked by likelihood
•Clinical reasoning explaining your thought process
•Risk stratification (severity, acuity, stability)
•Complications or concerns being monitored
•Response to treatment (for follow-up visits)

Building a Differential Diagnosis

A differential diagnosis is a list of possible conditions that could explain the patient's presentation. Build your differential systematically: **1. Start broad, then narrow** Consider all possibilities, then use your data to rule in/out **2. Think 'worst first'** Always consider life-threatening conditions first **3. Use pattern recognition** Classic presentations suggest common diagnoses **4. Consider epidemiology** Age, sex, risk factors affect likelihood **5. Apply clinical evidence** Use your S and O data to support or refute each diagnosis

📋 Differential Diagnosis Example: Chest Pain

**Assessment:**
Working Dx: Acute Coronary Syndrome — rule out STEMI

**Clinical Reasoning:**
58 y/o male with substernal chest pressure, diaphoresis, and radiation to left arm. Multiple cardiac risk factors (HTN, DM, smoking, family history). Presentation concerning for ACS.

**Differential Diagnosis:**
1. **Acute MI** — Most likely given classic presentation and risk factors
2. **Unstable Angina** — If biomarkers negative
3. **Pulmonary Embolism** — Less likely, no hypoxia, no leg symptoms
4. **Aortic Dissection** — Less likely, no tearing pain, no BP differential
5. **GERD/Esophageal spasm** — Possible but must rule out cardiac first

**Risk Stratification:**
High-risk presentation requiring emergent evaluation

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The 'Aunt Minnie' Approach

Some presentations are so classic they're immediately recognizable — like recognizing your Aunt Minnie in a crowd. Examples: • Crushing chest pain + diaphoresis + radiation = Think MI • Worst headache of life + sudden onset = Think SAH • RLQ pain + fever + migration from periumbilical = Think appendicitis But always confirm with objective data — even Aunt Minnie can fool you.

Documenting Clinical Reasoning

Show your work. Document why you believe your diagnosis is correct and why you've ruled out alternatives: **Good assessment:** "Acute appendicitis suspected based on classic migration of periumbilical pain to RLQ, positive McBurney's point tenderness, rebound tenderness, fever, and elevated WBC. Alvarado score 8. Ovarian pathology less likely given negative pelvic exam and timing of LMP." **Poor assessment:** "Abdominal pain, possible appendicitis." The good assessment demonstrates reasoning. The poor assessment shows no thought process.

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Red Flags in Assessment

Always document when you've considered and ruled out dangerous conditions: • Chest pain → Document ACS, PE, dissection considered • Headache → Document SAH, meningitis, mass considered • Abdominal pain → Document surgical emergencies considered • Shortness of breath → Document PE, MI, tension pneumo considered This protects you legally and ensures critical diagnoses aren't missed.

Assessment Pitfalls

Avoid these common assessment errors:

•Anchoring bias — Locking onto first diagnosis without considering alternatives
•Premature closure — Stopping the diagnostic process too early
•Confirmation bias — Only seeing evidence that supports your diagnosis
•Diagnosis momentum — Accepting previous provider's diagnosis without question
•Failing to reassess — Not updating assessment when new data arrives
•Vague assessments — 'Abdominal pain' without differential or reasoning

Clinical Assessment & Differential Diagnosis

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