Assessment and plan Flashcards
What do you include in summarizing test results
Name of the rest
Result of the Test
Why the test was ordered (the differential the rest is ruling out or confirming)
Plan
a list outlining how the Doctor will treat and/or monitor the patient
Assessment
Diagnoses + Summary of the visit
What does the plan include
Recommended treatments for each diagnosis
Prescriptions ordered today
Studies, tests, labs, imaging ordered today
Follow up with other healthcare professionals
Follow up when the next appt should be
What is included in the assessment
Age and Sex of the patient
Diagnosis or different diagnosis
May also include…
HPI elements
Summary of physical exam
Summary of lab/imaging results
Prognosis
Basic structure for an assessment
Age and sex
PMHx (if relevant)
Diagnoses
Ex: The pt is a 78 y/o male with chronic COPD in acute exacerbation today
Two requirements for a result to be included in assessment
New: the result must be new as of last visit
Relevant: the results must be relevant to today’s diagnosis
What is relevant information?
Positive results confirming diagnosis
Negative results ruling out a diagnosis
ICD code = ?
specific numerical code specific to your diagnosis
Quality measures
questionnaires and/or assessments providers do to check risk and overall health of patients
