How to Write a Medical Assessment and Plan

Medical students must learn to write medical assessment and appropriate treatment plans. This is a skill they will use throughout their medical careers. The assessment must be concise and define the issue. The treatment plan must lay out the route the patient is to take on their own to care for the issue diagnosed. The clinician is responsible for writing the medical assessment and plan as well as directing the patient toward appropriate treatment.

Steps

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    Determine the chief complaint by listening to the patient's explanation and then briefly interpret the direct point of the issue.
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    Discuss with the patient how long the issue has been going on and put that information into the assessment report.[1]
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    List all relevant personal information about the patient such as age, gender, and even race. While they often appear trivial, these issues could play a part in the treatment plan as well as determining the severity of the problem.[2]
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    Reiterate the patient's complaint and what events may have led up to it in sentence form.[3]
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    List any previous steps taken by the patient and medical professionals to correct the patient's distress. You need to list not only what in the past history has created improvement, but also what has not worked.
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    Pay attention to details of any existing medical conditions. These can hinder proper healing or correction of the problem.[4]
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    Talk about the fact that accurately reporting these things is the responsibility of the patient once he or she receives the assessment from the physician.
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    Discuss the plan of action the patient needs to follow. It is also a good idea to mention the results that are hoped for along with the next steps if the first directions do not work.[5]
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    Maintain a total length of no more than 5 pages when writing the medical assessment and plan. Effective, yet brief, documentation of a patient's complaint is what you are after. You must be concise.[6]
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    Add your assessment and plan to the patient's file when completed.
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Warnings

  • The medical assessment and plan must be written after examination of the patient. There is no way to correctly create this document without examining the patient.
    ⧼thumbs_response⧽
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Things You'll Need

  • Pen
  • Medical assessment and plan format used by your office or hospital

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References

  1. ↑ https://med.ucf.edu/media/2018/08/Guide-to-the-Comprehensive-Adult-H-and-P-Write-up-2017-18.pdf
  2. ↑ https://meded.ucsd.edu/clinicalmed/write.html
  3. ↑ https://meded.ucsd.edu/clinicalmed/write.html
  4. ↑ https://www.ncbi.nlm.nih.gov/books/NBK482263/
  5. ↑ https://fcm.unm.edu/education/images/docs/template_clin_soap_note.pdf
  6. ↑ https://med.ucf.edu/media/2018/08/Guide-to-the-Comprehensive-Adult-H-and-P-Write-up-2017-18.pdf

About This Article

wikiHow is a “wiki,” similar to Wikipedia, which means that many of our articles are co-written by multiple authors. To create this article, volunteer authors worked to edit and improve it over time. This article has been viewed 34,651 times.
40 votes - 83%
Co-authors: 6
Updated: December 6, 2022
Views: 34,651
Categories: Medical Skills | Medical Studies

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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