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Component of an admission note
The assessment and plan (abbreviated A/P"
[1] or 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
References