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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. ==References== 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「Assessment and plan」の詳細全文を読む スポンサード リンク
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