[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [History taking and the interview](https://durgical.com/en/clinical-exam/#a-history) › From findings to diagnosis: problem list, differential and SOAP note [Clinical exam](https://durgical.com/en/clinical-exam/) · [History taking and the interview](https://durgical.com/en/clinical-exam/#a-history) # 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 ## Key points - SOAP: S (subjective, what the patient reports), O (objective, exam and results), A (assessment) and P (plan). - Problem list: each important finding or diagnosis is numbered and followed in every note. - The differential is ordered by likelihood, without leaving out serious diagnoses that must not be missed. - First look for one diagnosis that explains all the findings; in older adults several often coexist. - The plan has parts: diagnostic tests, management, patient education and follow-up. - Colombian regulation requires scientific reasoning: the record must show logically how the diagnosis and plan were reached. ## 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. ## Memory aid What they say, what I see, what I think, what I do: four sentences make a SOAP note. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/from-findings-to-diagnosis-problem-list-differential-and-soap-note/) ## Related - [The clinical history: its parts and their order](https://durgical.com/en/clinical-exam/the-clinical-history-its-parts-and-their-order/) - [Chief complaint and history of present illness](https://durgical.com/en/clinical-exam/chief-complaint-and-history-of-present-illness/) - [The pleuropulmonary syndromes: the comparison table to know](https://durgical.com/en/clinical-exam/the-pleuropulmonary-syndromes-the-comparison-table-to-know/) - [Early warning scores: NEWS2 and qSOFA](https://durgical.com/en/clinical-exam/early-warning-scores-news2-and-qsofa/) - [Nursing assessment: head-to-toe and focused assessment](https://durgical.com/en/clinical-exam/nursing-assessment-head-to-toe-and-focused-assessment/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) 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](https://www.minsalud.gov.co/Normatividad_Nuevo/RESOLUCI%C3%93N%201995%20DE%201999.pdf) (Ministry of Health (Colombia), 1999); [12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax](https://openstax.org/books/fundamentals-nursing/pages/12-3-collection-of-assessment-data) (OpenStax, Rice University, 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/from-findings-to-diagnosis-problem-list-differential-and-soap-note/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/from-findings-to-diagnosis-problem-list-differential-and-soap-note/