Assessment and plan

• 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
• * physical 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.