assessment and plan
{{Short description|Component of an admission note}}
The assessment and plan (abbreviated A/P"{{cite web |url=http://depts.washington.edu/uwmedres/policies/handbook/patient/docu.htm |title=UW Internal Medicine Residency Program |accessdate=2009-04-10| archiveurl= https://web.archive.org/web/20090328235024/http://depts.washington.edu/uwmedres/policies/handbook/patient/docu.htm| archivedate= 28 March 2009 | url-status= live}} 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.