Assessment and plan explained

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.

Notes and References

1. Web site: UW Internal Medicine Residency Program . 2009-04-10. https://web.archive.org/web/20090328235024/http://depts.washington.edu/uwmedres/policies/handbook/patient/docu.htm. 28 March 2009 . live.