Assessment and plan

Last updated October 04, 2019

The assessment and plan (abbreviated A/P"^[1] 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, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

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.
Smoking is a practice in which a substance is burned and the resulting smoke breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have been rolled into a small square of rice paper to create a small, round cylinder called a "cigarette". Smoking is primarily practiced as a route of administration for recreational drug use because the combustion of the dried plant leaves vaporizes and delivers active substances into the lungs where they are rapidly absorbed into the bloodstream and reach bodily tissue. In the case of cigarette smoking these substances are contained in a mixture of aerosol particles and gasses and include the pharmacologically active alkaloid nicotine; the vaporization creates heated aerosol and gas into a form that allows inhalation and deep penetration into the lungs where absorption into the bloodstream of the active substances occurs. In some cultures, smoking is also carried out as a part of various rituals, where participants use it to help induce trance-like states that, they believe, can lead them to spiritual enlightenment.
Alcohol, sometimes referred to by the chemical name ethanol, is a psychoactive drug that is the active ingredient in drinks such as beer, wine, and distilled spirits. It is one of the oldest and most common recreational substances, causing the characteristic effects of alcohol intoxication ("drunkenness"). Among other effects, alcohol produces a mood lift and euphoria, decreased anxiety, increased sociability, sedation, impairment of cognitive, memory, motor, and sensory function, and generalized depression of central nervous system function. Ethanol is only one of several types of alcohol, but it is the only type of alcohol that is found in alcoholic beverages or commonly used for recreational purposes; other alcohols such as methanol and isopropyl alcohol are toxic.
Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behaviour occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.

In medicine, a differential diagnosis is the distinguishing of a particular disease or condition from others that present similar clinical features. Differential diagnostic procedures are used by physicians to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. Often, each individual option of a possible disease is called a differential diagnosis.

A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient. Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests.

In medicine, a social history is a portion of the medical history addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

Related Research Articles

Headache is the symptom of pain anywhere in the region of the head or neck. It can occur as a migraine, tension-type headache, or cluster headache. Frequent headaches can affect relationships and employment. There is also an increased risk of depression in those with severe headaches.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. The diagnosis is made when the person has symptoms of both schizophrenia and a mood disorder—either bipolar disorder or depression—but does not meet the diagnostic criteria for schizophrenia or a mood disorder individually. The main criterion for the schizoaffective disorder diagnosis is the presence of psychotic symptoms for at least two weeks without any mood symptoms present. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, psychotic bipolar disorder, schizophreniform disorder or schizophrenia. It is imperative for providers to accurately diagnose patients, as treatment and prognosis differs greatly for each of these diagnoses.

Palpitations are the perceived abnormality of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart. It is both a symptom reported by the patient and a medical diagnosis.

Systems development life cycle Systems engineering term

In systems engineering, information systems and software engineering, the systems development life cycle (SDLC), also referred to as the application development life-cycle, is a process for planning, creating, testing, and deploying an information system. The systems development lifecycle concept applies to a range of hardware and software configurations, as a system can be composed of hardware only, software only, or a combination of both. There are usually six stages in this cycle: analysis, design, development and testing, implementation, documentation, and evaluation.

The Curriculum Council of Western Australia is a defunct government department that once set curriculum policy directions for kindergarten to year 12 schooling in Western Australia. It was located at 27 Walters Drive, Osborne Park, Western Australia 6017. The Curriculum Council was governed by the 1997 Curriculum Council Act.

A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.

The medical history, case history, or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

Step 2 Clinical Skills of the United States Medical Licensing Examination (USMLE) is an exam administered to medical students/graduates who wish to become licensed physicians in the U.S. It is similar to the COMLEX-USA Level 2-PE exam, taken by osteopathic medical students/graduates who seek licensure as physicians in the U.S. For US medical students, the exam fee is $1,285. For medical students at foreign medical schools, the tests cost is higher—currently $1,535. These fees do not include costs associated with travel and lodging to take the test. Historically, US students have taken Step 2 CS late in their senior year, prior to graduation. However, now that more residency programs require students to record a passing score, many US medical schools recommend students take Step 2 CS in the fall of their senior year.

The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.

The Ohio Graduation Test (OGT) is the high school graduation examination given to sophomores in the U.S. state of Ohio. Students must pass all five sections in order to graduate. Students have multiple chances to pass these sections and can still graduate without passing each using the alternative pathway. In 2009, the Ohio legislature passed an education reform bill eliminating the OGT in favor of a new assessment system. The development and transition of replacement began in 2014 and will end in 2022.

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that may look and feel well.

The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is used in a broad range of helping professions in health and social care settings as well as by medical and social science researchers.

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, but not deeper investigation such as neuroimaging. It can be used both as a screening tool and as an investigative tool, the former of which when examining the patient when there is no expected neurological deficit and the latter of which when examining a patient where you do expect to find abnormalities. If a problem is found either in an investigative or screening process, then further tests can be carried out to focus on a particular aspect of the nervous system.

Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients who require prompt medical attention to avoid long-term disability or death. In addition to addressing "true emergencies," emergency nurses increasingly care for people who are unwilling or unable to get primary medical care elsewhere and come to emergency departments for help. In fact, only a small percentage of emergency department (ED) patients have emergency conditions such as a stroke, heart attack or major trauma. Emergency nurses also tend to patients with acute alcohol and/or drug intoxication, psychiatric and behavioral problems and those who have been raped.

When buying a horse, many buyers ask for an equine prepurchase exam. This serves to identify any preexisting problems which may hinder a horse's future performance and reduce buyer risk. The inspection usually consists of four phases in which a veterinarian examines all aspects of the horse's health.

A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist, but it can be a multi-disciplinary process involving nurses, psychologists, occupational therapist, social workers, and licensed professional counselors.

In a medical encounter, a past medical history, is the total sum of a patient's health status prior to the presenting problem.

ITIL, formerly an acronym for Information Technology Infrastructure Library, is a set of detailed practices for IT service management (ITSM) that focuses on aligning IT services with the needs of business.

References

↑ "UW Internal Medicine Residency Program". Archived from the original on 28 March 2009. Retrieved 2009-04-10.

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.

[urlUW_Internal_Medicine_Residency_Program-1] "UW Internal Medicine Residency Program". Archived from the original on 28 March 2009. Retrieved 2009-04-10.