Assessment and plan

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The assessment and plan (abbreviated "A/P")[1] is a component of an admission note.

  • Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.
  • The plan is typically broken out by problem or system. Each problem should include:
    • brief summary of the problem, perhaps including what has been done thus far
    • orders for medications, labs, studies, procedures and surgeries to address the problem.
  • problems are commonly derived from
    • chief complaint
    • history of present illness
    • review of systems rarely, these should have been picked up and incorporated as new chief complaints during the interview
    • physical exam rarely, these should have been picked up and incorporated as new chief complaints during the exam
    • social history, including counseling for smoking, alcohol, and illicit drug use
    • family history
    • medications may indicate problems that need to be addressed in the treatment of the other problems, such as dyslipidemia controlled with a statin.

References[edit]

  1. ^ "UW Internal Medicine Residency Program". Archived from the original on 28 March 2009. Retrieved 2009-04-10.