Assessment and plan
From Wikipedia, the free encyclopedia
- 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.