Assessment and plan

The assessment and plan (abbreviated "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.