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:
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
PLAN:
– 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
Core measures:
– 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.