Do you struggle with creating an effective patient assessment or perhaps nervous about preparing for your patient presentation? Well, you’re in luck because in this post, we’re going to show you the steps on how to create amazing assessment and plans in medical school.
Let’s get into it!
What Makes A Great Patient Assessment Plan?
Among all the medical students I’ve seen, what usually separates top students from those that are struggling is their ability to do an effective patient assessment and plan, which is what you want to do as a medical professional.
So in this post, I really want to unpack all of this information and give you my step-by-step approach on how to create an amazing patient assessment and plan.
Knowing The Problem
The main difficulty that I find with patient assessment and plans (from medical students, nursing students, and all the students I’ve worked with) is that they’re not really organized. Part of it just comes from a lack of experience of being able to take care of a specific problem or truly identify what’s going on.
Now, if you’ve only seen a handful of patients altogether in a specific rotation, it would be harder for you to quickly determine what is going on, as compared to somebody who has seen a lot of patients in that specific kind of disease. That person would naturally have a better idea of what the differential should include.
So experience aside, I want to give you an approach that you can use whether you are on day number 1 or day number 120 on a specific rotation.
Throughout this entire process, I do recommend that if you have to write a History and Physical Examination (H&P), you might as well start typing up this problem list in your actual notes.
Steps On How To Create Amazing Assessments And Plans
Step #1 Create a Problem List
The first thing to do before creating a patient assessment and plan is to focus on creating a truly effective problem list. Now, this is something I see most residents and interns struggle with, so don’t be ashamed if you’re also having issues with this!
Truly being able to identify all the problems a patient has can really help you understand the things that need to be fixed and what you should be doing for each specific problem?
1. Note Patient Complaints
My systematic way of creating a very effective problem list is going to the first thing the patient is complaining about.
For example, if you have somebody who’s coming in with shortness of breath, then that will be problem number one, and so on. Once I get past the common main symptoms that the patient is complaining about, the next thing I’ll do is go systematically.
2. Check Vitals
First I’ll look at their vitals and see if there is anything there that I would consider to be a problem?
For example, if the patient’s heart rate is up, tachycardia would be a problem.
If they are on some kind of supplemental oxygen, then acute hypoxic respiratory failure would be another problem.
If their blood pressure is too low or too high, hypertension or hypotension would be the next problem.
3. See Lab Results
In a similar fashion, I would then go through the patients’ labs and try to find out if anything weird is going on with their BMP, CBC, or anything that has been ordered by either myself or another provider.
For example, in internal medicine, one of the things I put a lot of focus on are things like creatinine, and if I see that somebody’s creatinine is above their normal, I may call it acute renal insufficiency. And once again, you guessed it, add it as a problem.
4. Review EKGs And Imaging
Now, similar to lab results, I also like to go to my patients’ imaging and EKG just to add anything that may show up.
For example, a pulmonary nodule, infiltrates, or their EKG can start showing things like AFib or arrhythmias or heart blocks, and if they do, again you guessed it: Add it as a problem.
5. Go Through Their Meds
Now keep in mind, we’re doing all of this before ever reading about what the patient is really there for.
We’re not really reading the notes, we’re truly just going through their vitals, their lab results, their imaging… And now their meds – because that is what starts to give us an idea as a provider of what types of things this patient is being treated for outside of the hospital.
So for example, if I see that they’re on levothyroxine, then I can add hypothyroidism as a problem.
6. Review Patient Notes And Identify Other Medical Histories
Once you’ve gone through the process of reviewing the objective data, you can now go through your patient notes from their admission as well as from any office visits.
That way you can understand other medical problems that the patient has.
For example, if they had type 2 diabetes and it didn’t show up on their labs or you hadn’t been able to pick it up on their medications, you can now add that to your problem list.
At this point, you now have a full list of all the problems you can identify for the patient.
This is something I really started doing effectively as a first year doctor, but I definitely see attendings who really like this approach.
For example, one of the cardiologists I currently work with loves to ask current interns to list the top 10 things that are wrong with each patient every time they present a new one to him.
This makes for an effective method to get interns to start focusing on not only the most common factors like chest pain, but also other factors like homelessness, abuse of a substance, or anything else that may show up. That way all possible factors are added and accounted for.
Step #2 Categorizing Common Problems
Seems quite a lot to take, doesn’t it? Now we’re finally starting to get into the actual patient assessment.
Once you can identify all the problems that they have, the next thing you’ll want to do is to start grouping together common symptoms and problems into major categories, if possible.
So for example, if you have a patient who comes in with a fever – they’re tachycardic. And then their white blood cell count or their heart rate’s up, and they have leukocytosis, they basically can get reclassified as sepsis.
Sometimes you may not even be able to necessarily classify them; they can all just go under one chunk in your notes. You can have all four problems as one kind of chunk where you’ll have to determine why you think that is as well as what you want to do for it.
With these steps, I can truly start understanding the patient. I can start seeing lab abnormalities that may fit with vital abnormalities or with the medication that they’re currently taking.
For one, it really helps me broaden my differential as well as gives me a direction of what I want to do for management’s sake.
Step #3 Prioritize What To Treat
Now once you’ve grouped your problem list, start prioritizing based on the most important problem that you want to take care of.
Often, depending on the attending, this may be the thing that the patient came complaining about or the most critical issue they may have going on.
So just because a patient comes in with shortness of breath, that may not necessarily be the main thing you treat for them as a provider. Start prioritizing what is problem number one, two, and three for those patients.
Usually, towards the end, everything happens to be either chronic things or things that you’ll just work on an outpatient.
Not only have you created a problem list and grouped together the major problems, you’ve also been able to prioritize them accordingly.
Now, the next time your attending or your resident asks you questions like, “What are the main things we’re doing for this patient?”, you won’t have to feel lost and you’ll have an idea about what you will do if you were that patient’s doctor.
Step #4 Do Differentials
The next step is to get to the assessment part of the patient assessment and plan.
Now that you see each problem, you’ll want to start thinking about the differentials. So for example, if you say that a patient has leukocytosis, a fever, and tachycardia, you’ll want to call it sepsis. One thing you can add to your notes, aside from the problem classification, is the reason why you think it’s happening.
What do you think are the infectious sources for this person that you think is septic? Is it urinary? Is it respiratory? Is it GI? Is it meningitis?
These are problems you would write and think about. You also have to create a mini-management checklist for each of them.
So for example, you had somebody come in with shortness of breath and your first problem was dyspnea on exertion. You look at other problems that the patient may have and you see that they’re tachycardic – so your differential should include things like pulmonary embolism and acute or chronic congestive heart failure.
Step #5 Making A Patient Assessment
Once you start adding your differential, you’re then able to create this mini management checklist of things that you want to do to work up each thing in your differential.
For example, you may want to do a Pulmonary Embolism (PE) workup, D-dimer, DVT ultrasound, CTA of the chest, a repeat echo, or start giving them diuretics to see if they’ll respond.
These are some of the things that go under a mini management checklist. And it is a great way for you to avoid missing out on things that you want to do for the patient.
Often I find med students and new trainees really struggling to get past some of the main things they need to do for that patient.
For example: A patient comes in with an infected wound and I’ll ask the medical students what they want to do. They may say, “Oh, I want to treat them with antibiotics“. But they haven’t really thought about what antibiotics to treat for, how long to treat it, how they want to work up for what the infection is (like getting a culture), as well as what they want to do for the patient in the short term (give them fluids, monitor their labs, etc.)
These are all things that go in for a patient that you might think is septic. And again, this pretty much comes with experience.
You’ll want to start having a mini checklist of what you want to do for each patient with congestive heart failure, for example, from today up to the rest of your career. That may include:
- What do you want to do for their volume status – are they volume up? Are they volume down?
- Do you want them on a beta blocker?
- Do you want them on lisinopril?
- Do you want them on spironolactone?
- Do you want them on other fancy medications?
- Do you want to get a repeat echo?
- Why do you think that they’re in heart failure?
Those above are things that you’ll want to add to your mini checklist. And a pro tip I recommend is: After having made your first note for that patient with congestive heart failure, see how you can make a template for the next time you have another patient with similar issues.
There are note writers and electronic medical records that may be able to help you save templates, and now that I have a recorded template of that, whenever I have a patient with heart failure, I can literally just type in my initials plus CHF, and the rest of the template is generated.
The first thing it will ask me is: What’s their ejection fraction? What are their home medications? After typing those out, it will ask: Do you think this patient’s volume is up?
I’d then also write down what I want to do for their volume status. Do I want to do a beta blocker? Do I want to get a repeat echo?
It’s kind of a checklist that I don’t have to start thinking about or retyping every single time. It just keeps me in check to make sure that I do all of the workup as well as all the medication management that I should be doing for that specific patient.
So once you can create these mini management checklists of every single problem, each time you see a patient with similar issues in the future, you start to get better at hitting all the checkboxes.
Another great example we can use is a patient that comes in with atrial fibrillation. One of the most common questions you may get asked is what their CHADSVASC score is as it can represent how high of a stroke risk that patient has.
The next thing you can be asked is how you want to treat them. Do you want to control the rate of how fast their heart’s moving, or do you want to control the actual rhythm – the actual atrial fibrillation?
With a mini management checklist now ready, whenever I write a note, I’ll have AFib and then I’ll have their CHADSVASC and then type in what their score is.
I’ll have Rate, and I’ll say what medication I’m treating their rate with.
I’ll have Rhythm and I’ll indicate if I’m ever even treating their rhythm.
And the final thing I’ll want to talk about is if this patient needs to be on blood thinners.
So I’ll write down what kind of medications they should be on or are on at home for their blood thinners.
But again, it’s a very systematic checklist so I don’t have to think very hard about it. I just know my approach already.
And every time you see a problem like that, whether it’s prenatal care or hypertension, you’ll want to have a mini checklist of what you can do.
Now your note becomes more efficient, your patient assessment becomes more efficient and definitely your plans for that problem become more focused.
So let’s just put all of that up here for review.
1. Create a problem list
Go ahead and start with a very long problem list – going through, very systematically, the patient’s vitals, their labs, their imaging, their medications, and then finally, other past medical histories.
2. Group problems together
Group common problems based on what you think they are related to.
3. Prioritize what to treat
Start organizing based on your priorities for each problem so that you can really focus on your management for each of them.
4. Do differentials
Start creating mini differentials for each of these problems.
5. Make a patient assessment
Finally, start creating a mini-management checklist for each problem.
So for somebody who comes in with sepsis, what do you want to do for fluids? What do you want to do for antibiotics? What do you want to do for a workup of the infection?
Pro tip: Save templates
If you do have an electronic medical record or a system that allows you to save templates, save them! That way you can write notes more efficiently and be able to remind yourself of all the things that matter for a specific problem. Definitely take advantage of that.
And that, my friend, is my step-by-step approach on how to make your patient assessment and plans as effective as possible. It’s the same thing I was using as a med student and the same thing I now more efficiently use as a medical physician.
If you have any questions, definitely drop them down below in the comment section and I may be able to answer them on my next blog!
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I hope you enjoyed this post about how to create amazing patient assessments and plans in medical school. If you did, I suggest you go read these posts as well:
- How To 10x Your Clinical Rotations Results: A Simple System
- What Are Clinical Rotations Like? [Detailed Breakdown]
- A Typical Day Of A Medical Student
- 20 Best Anatomy And Physiology Books For Medical Students
- How To Be More Efficient On Your Rotations [Medical Students And Residency]
Thank you so much for making it to the very end. Hopefully, I’ve been a little help to you on your journey. Thank you, as always, for being part of mine.
Until the next one my friend…