Clinical exam · History taking and the interview
From findings to diagnosis: problem list, differential and SOAP note !
- Topic
Clinical reasoning puts together what the patient tells and what is found to reach the most likely diagnoses and a plan.
Updated 2026-11-01
What it is
Clinical reasoning is the step from data to judgment: symptoms and signs are grouped into syndromes, a problem list is built and, for each problem, a differential diagnosis ordered by likelihood and severity. This assessment is written in the record and justifies the plan. Progress notes use the SOAP format: subjective, objective, assessment and plan.
Key facts
- S: symptoms and course since the last note, in the patient's words.
- O: vital signs, focused exam and laboratory and imaging results.
- A: interpretation of the data, main diagnosis, differentials and status of the problem (better, same, worse).
- P: tests, management, education, referrals and follow-up criteria.
- Common reasoning errors: premature closure and anchoring on the first impression.
Step by step
- Gather the data: history, physical exam and available results.
- Identify the key findings and group them into syndromes (for example, a lung consolidation syndrome).
- Write the problem list, from most to least urgent.
- For each problem, propose two to five differential diagnoses with the data for and against.
- Decide which tests would confirm or rule out each hypothesis.
- Write the plan and explain it to the patient: 'What we think you have is... and what we are going to do is...'
- In each progress note, update the SOAP note problem by problem.
Test yourself
Think of the answer, then tap the question to see it.
What does each letter of the SOAP note stand for?
Subjective (what the patient reports), objective (exam and results), assessment (interpretation and diagnoses) and plan (tests, management, education and follow-up).
How is a differential diagnosis ordered?
By likelihood given the patient's data, without leaving out serious or treatable diagnoses that must not be missed even if less likely.
What is premature closure in clinical reasoning?
Accepting the first diagnosis that seems to fit and no longer considering other possibilities before it is confirmed.
In which part of the SOAP note are vital signs written?
In the objective part (O), with the physical exam and test results.
Related
- The clinical history: its parts and their order
- Chief complaint and history of present illness
- The pleuropulmonary syndromes: the comparison table to know
- Early warning scores: NEWS2 and qSOFA
- Nursing assessment: head-to-toe and focused assessment
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Resolución número 1995 de 1999 (julio 8): por la cual se establecen normas para el manejo de la Historia Clínica (Ministry of Health (Colombia), 1999); 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024).
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Representative model, for educational purposes only.