27 lines
1.2 KiB
Markdown
27 lines
1.2 KiB
Markdown
---
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title: "Assessment and plan"
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chunk: 1/1
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source: "https://en.wikipedia.org/wiki/Assessment_and_plan"
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category: "reference"
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tags: "science, encyclopedia"
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date_saved: "2026-05-05T07:26:13.697908+00:00"
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instance: "kb-cron"
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---
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The assessment and plan (abbreviated A/P" or A&P) is a component of an admission note.
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Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.
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The plan is typically broken out by problem or system. Each problem should include:
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brief summary of the problem, perhaps including what has been done thus far
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orders for medications, labs, studies, procedures and surgeries to address the problem.
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problems are commonly derived from
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chief complaint
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history of present illness
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review of systems (rarely; these should have been picked up and incorporated as new chief complaints during the interview)
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physical exam (rarely; these should have been picked up and incorporated as new chief complaints during the exam)
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social history, including counseling for smoking, alcohol, and illicit drug use
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family history
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medications may indicate problems that need to be addressed in the treatment of the other problems, such as dyslipidemia controlled with a statin.
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== References == |