Assessment and plan

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

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