Assessment and plan

[starstarie]

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Hey all,

Right now I'm on outpatient medicine and I was wondering if anyone had any input on a good structured way to form an assessment and plan so you don't miss anything. I heard from one of my residents a while back about a way to think about the plan but I can't remember what it was anymore. I know it had something about breaking the plan down into parts like for example:

1. Suspected problem
- test to dx
- treatment of sx (??)
- etc. (It was such a good way to think ab it but I just can't remember what was included)

I feel like right now having a structured way would be really helpful.

Thanks!

 

[okokok]

My school's protocol is to break A into top three hypotheses with support for and against each one. The second paragraph is a little thing about the severity and urgency of the likeliest diagnosis. The P is broken up into diagnostic tests to order, therapy/drugs to prescribe, and patient education. My school has drilled this structure into our heads super hard.

 

[mvenus929]

On inpatient, I think the easiest way to develop plans is by system, because there are things that aren't necessarily problems that you still want a plan for (nutrition, etc), but some people find it easier to sort by problem.

On sick visits, the assessment is all about the differential, so coming up with a good way for you to think about the different possibilities is key. You want to include some information about why the diagnosis highest on your differential is highest and why the others are less likely. Then your plan is how you are going to distinguish between those diagnoses-- including imaging and lab work, and how you are going to treat it. Sometimes the treatment will be time. Other times, it will be a prescription of some variety. Then you want to know planned follow up. I can't think of anything else routinely included in the plan.

On routine visits, going by problem list is going to be the most useful, as this is how you are going to be paid.

 

[VA Hopeful Dr]

-Suspected problem: Why you think its this, why you think its not anything else, any testing you think you need to prove this, what you're going to do about it, follow up plans, patient education.

Example:
Knee pain - Suspect osteoarthritis given age, morning stiffness relieved with activity, and crepitis on exam with no other findings. X-ray ordered to confirm. Consider inflammatory markers if concerned for autoimmune disease. If xray shows arthritis, trial of scheduled tylenol. F/u in 2-3 weeks to recheck.