Medicine:Assessment and plan
The assessment and plan (abbreviated A/P[1] or A&P) correspond to the final two components of the SOAP note format, which is a widely used method of clinical documentation.[2]
The assessment section includes a synthesis of subjective and objective information to formulate a differential diagnosis. This information is gathered from the patient's history of the present illness, physical examination, laboratory studies, and imaging findings, when applicable.[3] Differential diagnoses may be prioritized in order of their likelihood or clinical significance.[4]
The plan outlines diagnostic testing, interventions, monitoring, patient education, and follow-up recommendations intended to address the problems identified in the assessment.[2] Plans are often organized by problem or organ system. Each active issue should be followed with diagnostic and therapeutic recommendations. These may include medications, laboratory studies, procedures, and surgeries.
- 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
- E.g., dyslipidemia controlled with a statin.
See also
References
- ↑ "UW Internal Medicine Residency Program". Archived from the original on 28 March 2009. https://web.archive.org/web/20090328235024/http://depts.washington.edu/uwmedres/policies/handbook/patient/docu.htm. Retrieved 2009-04-10.
- ↑ 2.0 2.1 Maldonado, Daniel; Zúñiga, Cynthia (2024). SOAP for Family Medicine (3rd ed.). Wolters Kluwer (Lippincott Williams & Wilkins). ISBN 9781975216481.
- ↑ Cameron, Susan; Turtle‐Song, Imani (2002). "Learning to Write Case Notes Using the SOAP Format". Journal of Counseling & Development 80 (3): 286–292. doi:10.1002/j.1556-6678.2002.tb00193.x. ISSN 0748-9633. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x.
- ↑ Weed, Lawrence L. (1964-06-01). "Medical records, patient care, and medical education" (in en). Irish Journal of Medical Science (1926-1967) 39 (6): 271–282. doi:10.1007/BF02945791. ISSN 0021-1265. https://doi.org/10.1007/BF02945791.
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