Assessment and plan
Encyclopedia
The assessment and plan is a component of an admission note
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Admission note
An admission note is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care...
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- 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.