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The Assessment and Plan (A&P) is the concluding diagnostic and therapeutic synthesis of a clinical encounter note, following the SOAP Note Subjective (S) and SOAP Note Objective (O) sections. Originally formalized by Lawrence Weed in 1968 as part of the Problem-Oriented Medical Record (POMR), the Assessment and Plan documents the clinician’s differential reasoning, working or definitive diagnoses, disease stability, and actionable diagnostic, therapeutic, and follow-up orders—and serves under the 2021 and 2023 AMA/CMS Evaluation and Management (E/M) guidelines as the primary determinant of Medical Decision Making (MDM) coding levels.
What Should Be Included in an Assessment and Plan Template?
To satisfy clinical communication standards, hospital clinical documentation integrity (CDI) audits, and CMS E/M Medical Decision Making rules, a complete Assessment and Plan entry for each clinical problem must include six core elements:
- One-Line Summary Statement (Clinical Synthesis / “Illness Script”): A concise opening sentence synthesizing patient age, relevant baseline comorbidities, presenting acuity, and key Objective findings (e.g., “68-year-old male with HFrEF (EF 35%) and CKD Stage 3b presenting with 4 days of progressive orthopnea, 6-lb weight gain, and elevated NT-proBNP.”).
- Numbered Problem Title with Specificity and Acuity: The most specific supported clinical diagnosis or high-priority symptom (mapped to an ICD-10-CM and SNOMED CT concept), explicitly stating status and acuity (e.g., acute vs. chronic, stable vs. worsening/exacerbated, controlled vs. uncontrolled, and anatomical laterality/stage).
- Differential Diagnosis and Clinical Reasoning (Assessment): For undiagnosed symptoms or acute presentations, a ranked list of differential possibilities explaining why the leading diagnosis is favored, which red-flag conditions were considered or ruled out, and how independent interpretation of labs, imaging, or external records informed the assessment.
- Diagnostic Workup Plan: Specific laboratory panels, microbiological cultures, imaging modalities, physiological tests (e.g., ECG, spirometry), or procedures ordered during the encounter.
- Therapeutic & Medication Management Plan: Specific pharmacologic interventions (stating whether medications are initiated, titrated, continued, or discontinued, along with clinical risk monitoring), non-pharmacologic therapies, and specialty consultations or referrals.
- Patient Education, Safety Netting, and Follow-Up Interval: Shared decision-making discussions, social determinants of health (SDOH) barriers addressed, explicit return-precaution (“red flag”) instructions, and the scheduled follow-up timeframe.
Problem-Based vs. Organ-System-Based Assessment and Plan
Clinicians use two distinct structural layouts when drafting an Assessment and Plan template, depending on the care setting and patient acuity:
| Dimension | Problem-Based Assessment & Plan | Organ-System-Based Assessment & Plan |
|---|---|---|
| Organizational Unit | Numbered active clinical diagnoses or presenting problems (#1 Acute Decompensated Heart Failure, #2 CKD Stage 3b) |
Anatomical/physiological organ systems (Neuro, CV, Pulm, GI/FEN, Renal/ID, Heme/Prophylaxis, Dispo) |
| Best Clinical Setting | Outpatient primary/specialty clinics, emergency departments, and general medical-surgical wards | Intensive Care Units (MICU, SICU, CCU) and complex multi-organ critical care rounds |
| CMS E/M MDM Audit Alignment | Directly aligns with the AMA/CMS MDM grid (makes counting the number, acuity, and stability of problems transparent) | Ensures no physiological support system (ventilator, pressors, sedation, DVT/GI prophylaxis, lines) is overlooked in critical illness |
Reusable Assessment and Plan Templates (Copy-Ready)
Template 1: Problem-Based Outpatient / Inpatient Ward A&P Template
ASSESSMENT AND PLAN
Clinical Summary: [Age]-year-old [sex] with past medical history of [key comorbidities] presenting with [chief complaint / duration], notable on exam/workup for [key pertinent positive/negative findings].
#1. [Primary Diagnosis or Presenting Symptom] — [Acuity: Acute / Chronic] | [Status: Stable / Worsening / Uncontrolled]
- Assessment / Differential: [Clinical reasoning; leading diagnosis vs. differential possibilities ruled out; summary of labs/imaging/external records reviewed].
- Diagnostic Plan: [Labs, imaging, diagnostic studies ordered today].
- Therapeutic Plan: [Medications started, adjusted, continued, or stopped; non-pharmacologic interventions; referrals].
- Monitoring & Goals: [Target clinical endpoint, e.g., BP <130/80 mmHg, HbA1c <7.0%, repeat metabolic panel in 2 weeks].
#2. [Secondary Diagnosis / Comorbidity] — [Status: Stable / Exacerbated]
- Assessment: [Current disease control, adherence, and interaction with Problem #1].
- Plan: [Continue/adjust regimen; surveillance labs or screenings].
#3. Preventive Care / Health Maintenance / SDOH
- [Immunizations, age-appropriate cancer screenings, fall/depression screening, or social barriers to care].
Disposition & Follow-Up:
- Patient counseled on diagnosis, treatment risks/benefits, and strict return precautions ([list specific red-flag symptoms]).
- Follow up in [timeframe] or sooner if symptoms worsen.Template 2: Organ-System-Based Critical Care (ICU) A&P Template
ICU ASSESSMENT AND PLAN (By System)
One-Liner: [Age]-year-old [sex] admitted on [ICU Day #] for [primary critical illness], currently [intubated / on vasoactive support / improving].
1. Neurologic (Pain / Agitation / Delirium): [GCS / RASS target; CAM-ICU status; analgesia and sedation regimen].
2. Cardiovascular (Hemodynamics / Rhythm): [MAP target; vasoactive infusions; volume status; rhythm/rate control].
3. Pulmonary (Ventilator / Oxygenation): [Ventilator mode, TV, PEEP, FiO2; ABG/SpO2; spontaneous awakening/breathing trial (SAT/SBT) plan].
4. Gastrointestinal / Nutrition (FEN): [Enteral vs. parenteral nutrition; bowel regimen; glycemic target; stress ulcer prophylaxis].
5. Renal / Electrolytes / Acid-Base: [24-hr fluid balance / UOP; Cr/eGFR trend; electrolyte repletion; RRT/dialysis settings].
6. Infectious Disease: [Tmax, WBC/procalcitonin trend; culture results; active antimicrobials with Day # and planned stop date].
7. Hematology / Prophylaxis: [Hgb/Plt/Coags; pharmacologic vs. mechanical VTE prophylaxis].
8. Lines, Tubes & Drains: [Central line, arterial line, Foley catheter necessity review].
9. Goals of Care & Disposition: [Healthcare proxy, code status, family update, transfer readiness].Worked Clinical Example (Fictional Outpatient Encounter)
ASSESSMENT AND PLAN
Clinical Summary: 64-year-old female with Type 2 diabetes mellitus, essential hypertension, and Stage 3a chronic kidney disease presenting for 3-month chronic care follow-up and 2 weeks of home blood pressure readings averaging 152/90 mmHg.
#1. Essential Hypertension (ICD-10-CM: I10) — Chronic, Uncontrolled
- Assessment: Above ACC/AHA target of <130/80 mmHg despite adherence to lisinopril 20 mg daily. Home BP log reviewed and validated against in-office repeat BP (150/88 mmHg). No headache, chest pain, dyspnea, or visual changes. Serum potassium (4.3 mEq/L) and creatinine (1.18 mg/dL, eGFR 52 mL/min/1.73m²) reviewed today—stable from 3 months ago.
- Diagnostic Plan: Order spot urine albumin-to-creatinine ratio (uACR).
- Therapeutic Plan: Initiate amlodipine 5 mg PO once daily in addition to continuing lisinopril 20 mg PO daily (prescription drug management; counseled on potential peripheral ankle edema and dizziness).
#2. Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (ICD-10-CM: E11.22) — Chronic, Stable
- Assessment: Point-of-care HbA1c today is 6.8% (down from 7.3% three months ago). Tolerating metformin XR and empagliflozin without hypoglycemia or genitourinary symptoms.
- Therapeutic Plan: Continue current glycemic and SGLT2-inhibitor regimen; annual dilated retinal exam referral placed.
#3. Chronic Kidney Disease, Stage 3a (ICD-10-CM: N18.31) — Chronic, Stable
- Assessment: Baseline eGFR 52 mL/min/1.73m² stable; nephroprotective ACE inhibitor and SGLT2 inhibitor active. Advised strict avoidance of over-the-counter NSAIDs.
Disposition & Follow-Up:
- Patient instructed to log home BP twice daily and send message via patient portal in 2 weeks; return to clinic in 6 weeks for BP re-check, or seek urgent care for BP >180/120 mmHg, chest pain, or shortness of breath.How Is an Assessment and Plan Template Structured in EHR Workflows?
In modern electronic health records and AI SOAP note generator pipelines, the Assessment and Plan is stored both as a human-readable clinical narrative and as discrete, machine-actionable interoperability structures:
- CMS 2021/2023 E/M Medical Decision Making (MDM) Substantiation: Because history and physical exam bullet counting no longer determines E/M levels (CPT 99202–99215 and 99221–99233), the Assessment and Plan carries the burden of proving two of the three MDM elements: (1) Number and Complexity of Problems Addressed (e.g., 1 stable chronic illness = Low; ≥2 stable chronic illnesses or 1 chronic illness with exacerbation = Moderate; 1 chronic illness with severe exacerbation posing threat to bodily function = High), (2) Amount/Complexity of Data Reviewed, and (3) Risk of Patient Management (e.g., prescription drug management = Moderate risk; decision regarding hospitalization or parenteral controlled substances = High risk).
- LOINC and HL7 C-CDA R2.1 Section Codes: When an EHR exports a clinical note as an HL7 Consolidated CDA (C-CDA) document, a combined Assessment and Plan maps to
LOINC 51847-2(Evaluation + Plan note, C-CDA template OID2.16.840.1.113883.10.20.22.2.9). If the EHR separates the two sections, the Assessment maps toLOINC 51848-0(Evaluation note, OID2.16.840.1.113883.10.20.22.2.8) and the Plan maps toLOINC 18776-5(Plan of care note, OID2.16.840.1.113883.10.20.22.2.10). - HL7 FHIR R4 Resource Mapping: Within problem-oriented EHR charting (such as Epic Problem-Oriented Charting), each problem header in the A&P links to a discrete FHIR
Conditionresource (`clinicalStatus`, `verificationStatus`), the clinical synthesis maps toClinicalImpression, prospective care goals and interventions map toCarePlan,MedicationRequest, andServiceRequest, and the signed note text is indexed viaDocumentReference(coded with LOINC `51847-2` or `11506-3` Progress Note).
Frequently Asked Questions
What should be included in an assessment and plan template?
A complete Assessment and Plan (A&P) template should begin with a one-line clinical summary statement followed by numbered clinical problems. Each problem entry should state the specific diagnosis, acuity, and disease stability (e.g., stable vs. worsening), differential reasoning and data reviewed, diagnostic tests ordered, medication and therapeutic adjustments, and specific patient follow-up and return precautions.
How is an assessment and plan template structured in EHR workflows?
In EHR problem-oriented charting, each numbered A&P heading is linked to a discrete ICD-10-CM / SNOMED CT `Condition` record with associated medication (`MedicationRequest`) and lab/imaging (`ServiceRequest`) orders, and exported in HL7 C-CDA and FHIR `DocumentReference` exchanges under `LOINC 51847-2` (combined Assessment and Plan) or split into `LOINC 51848-0` (Assessment) and `LOINC 18776-5` (Plan of Care).
