I use an approach similar to one found in the Intern Survival Guide shown below with minor personal modifications.
Assessment and Plan:
Start with a one-line problem statement or summary statement (See Dr. Strong’s lecture)
__ year old M/ F patient with PMHx of (include all the relevant info/ diagnoses) presented with __ x duration.
Divide into two big categories: New or active medical problems and chronic medical problems.
Always state the likely diagnosis. If you are not sure, use “Probable/ Possible/ Likely/ Suspected”.
Document accurately. e.g., “Sepsis 2/2 to complicated UTI”, not urosepsis.
Always look for precipitating or exacerbating factors for worsening chronic medical conditions.
Calculate relevant scores/ scales for risk stratification:
- TIMI score for chest pain,
- CURB 65 score &/ or PSI/ PORT score for pneumonia,
- NIH stroke scale for stroke,
- GCS scale if AMS (+),
- Wells’ criteria for DVT/ PE,
- CHA2DS2-VASc score and HAS BLED score for Afib, etc.
Describe the workup and management plan for new problems. And also briefly mention the baseline function for chronic medical problems, e.g. Baseline PFT’s in COPD.
[* For pert +/- PE, break them into Present and Absent. For Pertinent +/- labs, imaging/studies: Break them into Done & Pending.]
NEW/ ACTIVE MEDICAL PROBLEMS:
# Chest pain r/o ACS, patient not actively having chest pain.
Pertinent +/- history (From CC, HPI, PMH, Risk factors, FH, SH, Med, Allergies, ROS): Acute onset, 1 hour ago, rated as severe 8/ 10 Left sided chest pain with radiation to Lf shoulder. Pt. has risk factors: Age, Tobacco smoking, HTN, HLD, and DM2. There is no prior hx of CAD, but positive hx of exertional chest pain and dyspnea.
Pertinent+/- P/ E findings: stable vitals, regular S1/ S2 without an obvious murmur.
Pertinent +/- labs: troponin, CK-MB, BNP, lactic acid, d dimer K, Mg, etc.
Pertinent+/- imaging/studies: EKG & CXR. If available, mention prior ECHO or Stress test/ MPI
– HEART score __ (I prefer the HEART score to the TIMI score ).
D/ Dx: – Possibly acute coronary syndrome (UA/ NSTEMI) – less likely GERD, Tietze disease/ viral costochondritis – Unlikely aortic dissection or pulmonary embolism
– In ER: s/ p IV morphine 4mg, oral aspirin 325mg, SL nitro
– Admit to medical floor/ ICU with telemetry monitor
– consulted cardiology Dr. __, pending recommendation
– STAT atorvastatin, metoprolol, Continue oral aspirin,
– SL nitro prn and IV morphine prn as long as BP tolerates
– continue home med: lisinopril, but hold NSAIDs
– serial troponin and EKG
– NPO for possible procedures – close
– close clinical monitor
CHRONIC MEDICAL PROBLEMS:
* HTN – diagnosed in 2005 – home BP monitoring -> 140/ 80’ s – continue home meds: lisinopril
*Insulin dependent type II DM – diagnosed in 2008 – home insulin regimen: Lantus & regular insulin (dose) +/- OHA (preferably hold metformin) – home glucose monitoring: FBS & RBS _. – last A1c – continue home regimen as above – add finger stick glucose TID & hypoglycemia protocol – continue to monitor
– Code status: full code or DNR or DNI
– GI PPx: PPI or H2-blocker
– DVT PPx: bilateral SCDs or heparin/ Lovenox depending on renal function
– lines/ tubes: PIV, Rt IJ central line or Foley’s cath Disposition:
– Currently inpatient for the treatment of __ The case was discussed with attending physician Dr. __ who was agreeable to above-mentioned plan.
The case was discussed with attending physician Dr. __ who was agreeable to above-mentioned plan.
Assessment & Plan
1. Write an effective problem statement, see Dr. Strong’s lecture.
2. Write out a detailed list of problems
From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.
3. Combine problems
Instead of doing a problem based where you list every single problem, try to combine the problems and either used a system based approach or an approach that links primary problems with secondary problems that are likely caused by the primary problems or go together and are treated together.
#GIB with anemia in the context of thrombocytopenia and mildly elevated coag studies
instead of listing GIB, Anemia, Thrombocytopenia, Elevated Coags separately as four problems.
#Worsening hypoxemic respiratory distress likely 2/2 to Non-small cell carcinoma of the RUL
PREP is a common mnemonic used in speaking which stands for Point, Reason, Example, Point. I think a modified version can help here.
Instead of Problem, Status, Plan, you can use PREP: Problem, Reason (etiology), Evaluation (status), Plan
If you don’t know the etiology, you can write, “unknown” or “likely due to”. If you know you use 2/2.