In patient care documentation, which section of the SOAP notes typically includes diagnosis and treatment plans?

The correct choice is the Assessment section of the SOAP notes. This section is critical because it consolidates the information gathered from the Subjective and Objective sections to develop a professional interpretation of the patient's condition. It typically includes the clinician's diagnosis based on the patient's complaints, the findings from examinations, and any relevant diagnostic tests. By synthesizing all this information, the Assessment effectively informs the healthcare provider of the patient's current status and the reasoning behind the chosen treatment strategies, which may also be reflected in the following section.

The separate segment of the Plan outlines the explicit treatment approach moving forward, but the actual diagnosis and the rationale for further treatments reside in the Assessment. This structure aids in ensuring clear communication among healthcare providers and supports a coherent treatment pathway for the patient, making it crucial for effective patient care documentation.