OP 5: Assessment and Plan

Question 1

Assessment

Answer 1

Where we list all the DX for the patient and summarize the visit.

Question 2

What is included in the assessment?

Answer 2

Must ALWAYS include:
- And and sex of the patient
- Diagnosis/Differential diagnosis

May include:
- HPI elements
- Summary of Physical Exam
- Summary of labs
- Prognosis (or justification for further testing or medication)
- Relevant Past medical history

Question 3

Assessment Structures

Answer 3

• Basic (one sentence that includes member age, sex, and Dx)
• Objective (2-3 sentence summary that includes basic info and relevant objective information rom the chart)
• Comprehensive (5-6 sentence summary that includes basic info and relevant subjective information form the chart (HPI elements))

Question 4

What are the requirements of results that are in the Assessment?

Answer 4

• New results
• Relevant results

Question 5

How to summarize a result?

Answer 5

Only include:
- Name of test
- Result of test
- Why its was ordered (was it to rule out/confirm illness, disease, or fracture?)

Question 6

Plan

Answer 6

A list outlining how the doctor will treat/monitor the patient. Typically spoken verbatim to the patient.

Question 7

What should be included int he Plan?

Answer 7

• Lifestyle changes (diet, exercise)
• OTC medications
• ANY specific instructions (wearing orthotics, stretching, etc.)
• RX
• Studies/tests/labs/imaging
• Referrals to other specialties
• Next follow-up with provider

Question 8

How is the Plan written?

Answer 8

• Bulleted/numbered list
• Each item should appear on a separate line
• Each Dx should have one bullet/number in the plan
• Group treatments for each Dx together
• Last bullet should be the timeline for follow-up (and what for: re-eval, results review, cast removal, etc.)

Question 9

International Classification of Diseases (ICD)

Answer 9

The billable code related to the diagnosis.