The Anatomy of Assessment

In order to properly understand the assessment portion of the chart note, it is necessary to understand the definition of the assessment as well as the difference between the assessment and problem.  

Assessment means: the evaluation or estimation of the nature, quality, or ability of someone or something.  In our case this could refer to the patient, the disease, the treatment, etc.

When a problem is listed  in the problem list it is usually some derivation of the chief complaint or list of complaints provided by the patient.  

For example:

  1. The actual problems listed for a given patient, Fred, is foot pain, headache, and occasional dizziness.  This is what the patient explained to the MA while being room, and what the MA documented into the chart as “CC” for this visit.  
  1.  This may or may not make it to the problem list “as is”.  In other words, Fred’s problem list may or may not contain the words “foot pain” or “dizziness”, but they absolutely have to be represented if these are to be considered as chronic problems with ongoing treatment over a medium to long-term period of time. 
  1.  Next comes the “assessment” portion of the progress or SOAP note and it is important to use professional medical language to do one of the following:
  1. Now the chart note should reflect the assessment from #3  above.  Using Fred as an example….