American Academy of Professional Coders (AAPC) Practice Exam

What typically follows the 'Assessment' section in SOAP documentation?

1. Recommendations

2. Plan

3. Diagnosis

4. Consent

The correct answer is: Plan

In SOAP documentation, which stands for Subjective, Objective, Assessment, and Plan, the 'Assessment' section is where the healthcare provider summarizes the patient's condition based on the subjective and objective findings. Following this, the 'Plan' section outlines the proposed course of action based on the assessment. This can include recommendations for treatment, further testing, referrals, or follow-up appointments. The 'Plan' is critical as it details how the provider intends to address the issues identified in the Assessment, thus ensuring that clear guidance is given for the patient's continued care. In contrast, while recommendations and diagnosis are important components of clinical documentation, they are not the specific term used in this context. Consent pertains to the patient's agreement to the proposed interventions but does not follow the Assessment directly in the SOAP structure.