A summary of significant data and physician conclusions is found in which section?

• A. Plan
• B. Chief Complaint
• C. Subjective Information
• D. Assessment

Answer: (D)

The Assessment section is where the clinician synthesizes the significant data from history, exam, and tests and states the diagnostic conclusions or impression. It captures the most likely diagnosis, the reasoning behind it, and any differential diagnoses under consideration. The Plan, by contrast, outlines the management steps, tests, and follow-up; the Chief Complaint is the presenting problem the patient reports; and Subjective Information includes the patient's own words about symptoms and history.