What does the SOAP A (Assessment) component typically include?

What does the SOAP A (Assessment) component typically include?

• A. Chiro diagnoses using ICD-10 codes, response to care, prognosis; must link subjective and objective findings.
• B. Treatment plan and modalities.
• C. Insurance verification and authorizations.
• D. Patient education materials.

Answer: (B)

Assessment focuses on the diagnostic impression and the patient’s current status, built by combining what the patient reports with what you observe in the exam. It typically includes the chiropractor’s diagnosis (often coded with ICD-10), the prognosis, and the clinical reasoning that ties together subjective findings (reported symptoms, history) with objective data (exam, tests). It may also note how the patient has responded to care so far. The treatment plan and modalities belong in the Plan, not the Assessment.

Assessment focuses on the diagnostic impression and the patient’s current status, built by combining what the patient reports with what you observe in the exam. It typically includes the chiropractor’s diagnosis (often coded with ICD-10), the prognosis, and the clinical reasoning that ties together subjective findings (reported symptoms, history) with objective data (exam, tests). It may also note how the patient has responded to care so far. The treatment plan and modalities belong in the Plan, not the Assessment.