The Assessment and Plan

The Assessment and Plan is the most critical part of the medical note. Because it is based on a clinician’s judgment, it can reflect both the best of our ability to synthesize a patient’s medical issues, and also the worst of our inherent biases. Language must be chosen with care, mirroring the words patients use in describing themselves whenever possible, particularly with regard to personal identities. It is impractical to suggest replacing succinct clinical jargon with lengthy phrases packed with qualifiers and caveats, but in many situations, simple word substitutions can make the difference between a note that conveys parentalism and judgment, and one that conveys a collaborative, patient-centered partnership. Thoughtful identification and naming of clinical problems, inclusion of phrases that neutrally capture the status of chronic conditions, and nuanced phrases that summarize in-person discussions of both the differential diagnosis and the plan can make medical notes a useful tool for patients in building their understanding of both their health and health care.

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Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Margaret Isaac & Sarah Leyde
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Editors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Christopher J. Wong
  2. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA Sara L. Jackson

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Isaac, M., Leyde, S. (2023). The Assessment and Plan. In: Wong, C.J., Jackson, S.L. (eds) The Patient-Centered Approach to Medical Note-Writing. Springer, Cham. https://doi.org/10.1007/978-3-031-43633-8_13

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