Medicine:Assessment and plan
From HandWiki
Short description: Component of an admission note
The assessment and plan (abbreviated A/P"[1] or A&P) 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
- ↑ "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.
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