Clinical Communication Intermediate Clinical Communication

Assessment and Plan (A/P)

Formal Definition

The clinical reasoning section of a note: your diagnosis (or differential) and what you're doing about it.

How It's Used on the Ward

"What's your A/P?" = What do you think is going on and what are we doing?

Example

"A: "Most likely community-acquired pneumonia given acute cough, fever, and right lower lobe infiltrate." P: "Start ceftriaxone + azithromycin, blood cultures x2, sputum culture, repeat CXR in 48h.""

Clinical Context

The A/P is where you demonstrate clinical reasoning. Problem-based A/Ps (organized by problem, not by system) are the modern standard.

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