Assessment and plan
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- 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.