The assessment and plan (abbreviated A/P"
or A&P) is a component of an
admission note
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the i ...
.
* 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 The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting pro ...
**
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
Genealogy () is the study of families, family history, and the tracing of their lineages. Genealogists use oral interviews, historical records, genetic analysis, and other records to obtain information about a family and to demonstrate kin ...
** medications may indicate problems that need to be addressed in the treatment of the other problems, such as
dyslipidemia
Dyslipidemia is an abnormal amount of lipids (e.g. triglycerides, cholesterol and/or fat phospholipids) in the blood. Dyslipidemia is a risk factor for the development of atherosclerotic cardiovascular disease ( ASCVD). ASCVD includes coronary ar ...
controlled with a
statin
Statins, also known as HMG-CoA reductase inhibitors, are a class of lipid-lowering medications that reduce illness and mortality in those who are at high risk of cardiovascular disease. They are the most common cholesterol-lowering drugs.
Low ...
.
References
{{Medical records
Medical terminology