Writing the PLAN

The identified problems are listed in order of severity (worst first). a. When the problem is a complaint or physical finding or lab result (e.g. dyspnea), then for each problem, then list at least three items of differential diagnosis, with the most likely first. For each differential diagnosis item, then write up the following: o o why is this likely or unlikely? what would you do to confirm or exclude it as a possibility?

b.

When the problem is the active diagnosis that is already known to you via history or known lab results (e.g. asthma), then do the following:
What is the evidence for your diagnosis (history, physical,

labs) What are the likely causative agents? (e.g. atherosclerosis, strep pneumoniae) Why did the patient get it? (risk factors, e.g. diabetes mellitus, smoking, alcoholism, AIDS) How would you further evaluate and treat it? (keep it simple, and explain your rationale) c. When the problem is a past medical problem that is important to remember then state:
the current activity of the problem how it is being treated any testing or changes in therapy you would recommend

d.

When the problem is one of routine prevention (Health care maintenance):

list the problem as Health care maintenance/prevention state specific things you would focus on in this patient to

improve their overall health.