Developing Assessment/plan?

[swtiepie711]

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I've had some rotations thus far where the team's A&P was very set in stone - either the team had a specific format we'd fill out at the bottom of our notes, or I'd do the 1 liner assessment, stick some thoughts about a plan in and then the intern would fill in the rest (it was surgery, the intern never had time to talk with me about it as we were always racing off to the OR).

Regardless, I'm now in outpatient medicine clinics and realizing my A&P skills suck. I think my H&P skills suck too, but at least I can come out of the room with a story & my physical, but then I tend to trail off and the doc usually says "ok, lets go see the patient" and it goes from there.

I guess have questions like - if a patient w/ h/o HTN & hyperlipidemia comes in for clinic with c/o cough, your differential is huge (URI, postnasal drip, GERD, neoplasm, ACEinhibitor, etc) - obviously from history you'd have that narrowed down and list some tests to differentiate or meds to initiate etc.
But do you put ALL of the patients problems in the plan? like
1. cough (likely due to...)
- tests or meds or whatnot
2. HTN - stable, BP 128/82
- continue XYZ med
3. Hyperlipidemia - uncontrolled, most recent LDL #
- Increase medX to #mg BID.

No one has ever sat me down to talk about how to develop the assessment/plan, things to think about etc. I've also never asked specifically - which is my fault. Regardless, is there a good format, way to think about things, website/book/outline way to think about it? Like I've noticed some people do "cough likely secondary to XYZ because ABC" and then a plan? Or is this so individual that there isn't a "format" per se (like there is for the History or physical exam?)? Thanks for any help or suggestions 👍

 

[Droopy Snoopy]

I've had some rotations thus far where the team's A&P was very set in stone - either the team had a specific format we'd fill out at the bottom of our notes, or I'd do the 1 liner assessment, stick some thoughts about a plan in and then the intern would fill in the rest (it was surgery, the intern never had time to talk with me about it as we were always racing off to the OR).

Regardless, I'm now in outpatient medicine clinics and realizing my A&P skills suck. I think my H&P skills suck too, but at least I can come out of the room with a story & my physical, but then I tend to trail off and the doc usually says "ok, lets go see the patient" and it goes from there.

I guess have questions like - if a patient w/ h/o HTN & hyperlipidemia comes in for clinic with c/o cough, your differential is huge (URI, postnasal drip, GERD, neoplasm, ACEinhibitor, etc) - obviously from history you'd have that narrowed down and list some tests to differentiate or meds to initiate etc.
But do you put ALL of the patients problems in the plan? like
1. cough (likely due to...)
- tests or meds or whatnot
2. HTN - stable, BP 128/82
- continue XYZ med
3. Hyperlipidemia - uncontrolled, most recent LDL #
- Increase medX to #mg BID.

No one has ever sat me down to talk about how to develop the assessment/plan, things to think about etc. I've also never asked specifically - which is my fault. Regardless, is there a good format, way to think about things, website/book/outline way to think about it? Like I've noticed some people do "cough likely secondary to XYZ because ABC" and then a plan? Or is this so individual that there isn't a "format" per se (like there is for the History or physical exam?)? Thanks for any help or suggestions 👍

The way you list it would be pretty standard for, say, a family medicine or IM clinic visit (the patient's primary care physician). If it's acute care or a specialty/subspecialty clinic maybe not so much. In that case you'd want to give a good differential and focus your plan on their CC only, the other stuff you'd only worry about if it'd be negligent not to (like a BP of 185/112 or something).

Anyway if for no other reason than practice, when in doubt always do more vs. less; it takes two seconds to mention the patient's other issues, and as a student (or resident even) you're sometimes not to the point where you can appropriately link a patient's acute and chronic problems.

 

[ChiDO]

The way we were taught to do the A/P in our H&P class was list your DDx from obviously #1 what you think it is to #4-5 (more then 3 to get full points on Step 2). Then, do a plan for your top ddx (meds, tests, "holistic", referral, return)

-ACEinhibitor SE
1. Discountinue ACE
2. Give ARB
3. (no tests)
4. (say something nice to the patient when you are explaining this, to get your "holistic" points)
5. (no referral - skip)
6. Call office in 1 week if cough persists.
-URI
-GERD
-Obsturction
-Post nasal drip

-Fx Bone
1. Give pain med
2. X-ray
3. Refer to orthopedic surgery
4. Admit to ortho service
-Sprain
-Ect
-Ect

 

[braluk]

For my plan I usually go systems base and discuss if we should continue/change/DC management decisions that were decided upon yesterday- I'll start with Gen to CNS and move down.

 

[psipsina]

For my plan I usually go systems base and discuss if we should continue/change/DC management decisions that were decided upon yesterday- I'll start with Gen to CNS and move down.

The two setups I've see are systems based (as above) or problems based. Systems based seems best in super complicated patients to make sure you don't miss anything, used mostly in ICU type settings. Problem based is good because for each problem on your problem list you generate a plan.

For example I'd say:
1) ARF (prerenal vs renal): continue IVF, follow CMP daily, get ANA, anti-dsDNA, RF, C3, C4, and renal u/s. (blah blah blah).
2) DM- d/c metformin due to increased Cre, put on sliding scale insulin, accucheck q4hr
3) Tobacco use - discussed smoking cessation with patient
. . . . .

I use uptodate to figure out ideas for management when I'm not familiar with them yet. In my institution we are expected to have plans but they don't need to be right, they just need to show that we're thinking about it and developing the skill so its not too scary. On the few rotations where the attending wanted the student note to have a correct plan I'd come up with my own and then my residents would help me out before I put it on the official note.

 

[swtiepie711]

I use uptodate to figure out ideas for management when I'm not familiar with them yet. In my institution we are expected to have plans but they don't need to be right, they just need to show that we're thinking about it and developing the skill so its not too scary. On the few rotations where the attending wanted the student note to have a correct plan I'd come up with my own and then my residents would help me out before I put it on the official note.

you mention uptodate for plan - is that for inpatient? I ask because i have zippo time on outpatient to come up with a A&P. I swear I go in & see the pt, I come out and the resident is right there wanting to know whats up. I have basically no time to synthesize/tihnk about things - I tell them what I know, we go in together, they generate a plan and we're off to see the next patient... it's rather frusterating b/c I have tons of questions and I never have time to ask....

thanks for the ideas! i appreciate the suggestions!

 

[braluk]

you mention uptodate for plan - is that for inpatient? I ask because i have zippo time on outpatient to come up with a A&P. I swear I go in & see the pt, I come out and the resident is right there wanting to know whats up. I have basically no time to synthesize/tihnk about things - I tell them what I know, we go in together, they generate a plan and we're off to see the next patient... it's rather frusterating b/c I have tons of questions and I never have time to ask....

thanks for the ideas! i appreciate the suggestions!

Usually in a heavy outpatient clinic setting where you're jet setting room to room between patients you will rarely have time in between to run through uptodate. I'll usually take a look at their past notes and briefly formulate a plan based upon it, depending on what they're here for, how long it's been since they've been seen, etc..etc.. Most often, in the outpatient clinics, you'll see a host of the most common things that patients come to see you for- these are things you should reference in uptodate before going to clinic. It's the zebras that you probably wouldn't of had read for. Occasionally, I'll grab the chart, review outside the room with Epocrates or other quick reference guide and come up with a differential/assessment/plan as I interview. After a while, patterns of problems can be empirically treated according to your patient demographics. I use uptodate for more complicated cases- right now I'm on Heme/Onc-Renal Pediatric inpatient, so most often, the workup will take at least a day or two to diagnose- plenty of time to run through your own research.

 

[psipsina]

Usually in a heavy outpatient clinic setting where you're jet setting room to room between patients you will rarely have time in between to run through uptodate. I'll usually take a look at their past notes and briefly formulate a plan based upon it, depending on what they're here for, how long it's been since they've been seen, etc..etc.. Most often, in the outpatient clinics, you'll see a host of the most common things that patients come to see you for- these are things you should reference in uptodate before going to clinic. It's the zebras that you probably wouldn't of had read for. Occasionally, I'll grab the chart, review outside the room with Epocrates or other quick reference guide and come up with a differential/assessment/plan as I interview. After a while, patterns of problems can be empirically treated according to your patient demographics. I use uptodate for more complicated cases- right now I'm on Heme/Onc-Renal Pediatric inpatient, so most often, the workup will take at least a day or two to diagnose- plenty of time to run through your own research.

Yeah in an outpatient setting I find its easier to go off the cuff. I usually look at the chart before going in and check dyna-med on my iphone if I've never heard the treatment plan/ddx for that presentation. In the inpatient setting I was definitely given 10-15 minutes to read about my patient if I wanted it and my residents would go over my plan with me except in a few rare instances when we were really really really slammed.

 

[sirscrubsalot]

These were was definitely some great suggestions! That's gotta be the most challenging thing for myself too; developing the thought process for creating the assessment/plan as stated by the original poster; not necessarily to outpatient vs inpatient. I still do share similar concerns as well.

My S/O's along with collecting a good history have been improving but not the A&P's... My PE is getting better too with more practice and time. I just want to improve more on learning the processes/reasoning in formulating a A&P - better to ask as a 3rd year rather than trip out during my electives and residency 🙄

I think the other tough part is figuring out which management step (plan) would be the best for whatever the condition, change of labs or physical exam positives (assessment), especially when all things like MGH pocket medicine or epocrates essentials list a bunch of different options. Somewhat challenging to sort from. 😱

It would be really cool to be able to get better at developing that thought process to where some of our preceptors and some students say for the A/P, "X - most likely (or i.e. secondary) due to XXXX, and we will do XXXXXX".

Anyone else know what I'm talking about and would care to share what's helped or currently helps them out? Thanks!

 

[Doctor Bob]

Anyone else know what I'm talking about and would care to share what's helped or currently helps them out? Thanks!

What helped the most for me was being wrong... a lot. My attendings through 3rd year encouraged me to come up with my own assessment and plan, then present it. Rarely was I right, but it always prompted a discussion that started with "ok, why do you think this is what they have" or "why do you want to do this plan". They'd make me defend my position before going on to explain why they had the same or diffferent A/P. I learned a lot more that way than by copying the resident's plans or transcribing a plan from a book or other resource.

That's what I do with medical students now that I'm on the other side of the table (so to speak). I encourage them to not worry about being wrong (I don't expect a 3rd year medical student to always get the assessment right, let alone get the plan right) and to devise their own plans. The key to making this work though is you have to have enough time to sit down and talk over the case. Sometimes finding the time for that requires creativity.

 

[sirscrubsalot]

What helped the most for me was being wrong...

I learned a lot more that way than by copying the resident's plans or transcribing a plan from a book or other resource.

I encourage them to not worry about being wrong (I don't expect a 3rd year medical student to always get the assessment right, let alone get the plan right) and to devise their own plans. The key to making this work though is you have to have enough time to sit down and talk over the case. Sometimes finding the time for that requires creativity.

Great points and thoughts to consider - appreciate it! I realize as students, at least for myself - becoming "masters of the A&P", (so to speak), is going to be a work-in-progress developmental skill throughout residency, and I'm willing to accept and look forward to that. I just need to continue practicing...

I think the latter part of your post regarding, having time to discuss a case with someone, is probably going to be the most challenging thing. That varies a bit with our preceptors; especially when some don't want to sit down/discuss to go over each A/P for every case. I think that's where some of my problems stem from.

Ok, if anyone else feels like they can share any other tidbits/thoughts, that would be always nice n' helpful!