Scribe Series: Assessment & Plan

Just like with everything else in medical writing, your Medical Decision Making (MDM) and assessment and plan will be different depending on your specialty and your provider’s preferences. I will try to walk you through how to go about writing this as a scribe. Ideally, your provider should be dictating this to you OR you should be taking the information that the provider relayed to the patient in the room and using it as your plan. As you improve as a scribe and understand your specialty more, your provider may have you write you own or at least start it on your own. Ultimately, the information should be coming from your provider!

What is an MDM/Assessment & Plan?

Well, by now you should be familiar with the SOAP note format. It is the easiest way to chart; and by easy I mean it makes the most sense to the most people. MDM and assessment and plan fit into the A&P section of the SOAP format.

Assessment (A) are the diagnoses or differential diagnoses that you are trying to rule out. In general, students are encouraged to list their differentials. Attendings with enough experience usually list what they are billing them for as the diagnosis in their assessment. If they are unsure of the diagnosis yet, they will put symptoms with a differential to work through.

The plan (P) is what you intend to do to narrow down the differential, treatment, and any counseling/education you give to your patient. This is a snapshot of what you are doing/intend to do so when you look back at the chart you can see what you’ve done and why. Most providers also give some sort of medical reasoning in with their plan to remind them what they were thinking of when they see the patient again; but not always.

MDM or Medical Decision Making is a combination of both. I saw this the most within the ER notes I was writing. They would write the MDM and discuss why they ruled a diagnosis in or out (reasoning behind their differential), important things they found on labs, and a brief recap of their pertinent HPI and PE. It was an explanation as to how they arrived at their diagnosis. It can also touch upon how the patient’s course was during the ER stay, so they have some reasoning to show why they discharged them, admitted them for observation, or had them admitted to the floor. Usually in my ER charts I would have a course section above the MDM, where many timestamped events were noted. It served as a snapshot to show what was done/why something was ordered/consults that were placed/advice given on consults/etc. That way, your MDM would just be about medical reasoning.

Then usually under the MDM in those cases you would have a diagnosis/assessment line. Here you would place your definitive diagnoses; since you had a paragraph or more above it going through your differentials and medical decision making.

Examples:

There are literally so many ways I have written these. It’s almost going to be difficult to provide a good way to break it down for you! But I will try my best.

The way I learned in medical school is as follows:

Assessment should be a one line containing the restatement of the patient’s name, age, and chief complaint. It should be followed by the differential diagnoses (which can usually be in bullet or number format) of what the patient’s symptoms may most likely be. Additionally, you would add any chronic diseases or pertinent history that you can count as a diagnosis.

The plan includes what you intend to obtain/do/counseling for the patient. For example:

Assessment: Patient is a 39 y/o M presenting with SOB. DDX include:
- asthma exacerbation
- pneumonia
- bronchitis
- H/o uncontrolled asthma 
- current smoker

Plan:
- albuterol nebulizer treatments q4 hours for 24 hours at home
- oral steroids
- CXR
- CBC, CMP, ABG

Now, this is a great way to teach students. It is also useful in settings such as internal medicine, family medicine, peds, etc where you are taking care of the patient’s chronic conditions. It can also be helpful in an inpatient setting where you are following the patient over several days. HOWEVER, it is not always used this way.

In the ER setting, as noted above, I would typically use the MDM method. It would look like the following:

MDM: Patient is a 39 y/o M with a h/o uncontrolled asthma and is a current smoker, presenting with SOB, wheezing, and a pulse ox of 88% upon presentation. On exam, he was noted to have inspiratory and expiratory wheezing bilaterally and decreased breath sounds on the L base, tripoding, and was in acute respiratory distress. His VS revealed tachycardia at a HR of 110 and hypoxia with a pulse ox around 88% on RA. He was immediately placed on a nasal cannula with slight improvement to 90%, and was later placed on a non-rebreather with his highest oxygenation at 92%. CXR revealed a patchy infiltrate to his L base. He was given a course of IV steroids, started on IV antibiotics, and given several nebulized albuterol treatments. Patient had some improvement in his symptoms post nebulizer treatments. He was admitted to pulmonology, Dr. Star, for further management. 

Diagnosis: 1. Pneumonia 2. Hypoxia 3. Uncontrolled asthma, likely exacerbation 4. Current smoker

Disposition: Admitted

Here, you can see the thinking behind why we did what we did. In more complicated cases, you would have several differential diagnoses that you would show you ruled in or out. For this one, the treatment/evaluation was more forward.

Now, a lot of times an MDM will show up in a different format. It will appear like a separate A&P, but essentially be a full MDM. I have seen this in internal medicine look something like this:

1. Diagnosis. talk about it. Why you are ordering labs, why you are concerned, and what you talked about with the patient and any at home things they need to do.
2. Next diagnosis. Same thing
3. Next diagnosis. You get the idea

Again, I used this a lot in my internal medicine and family medicine clinics as a scribe. That way, the A&P were together in one place and anyone reading the chart (but more likely the original physician who read it back before seeing them again) could see their diagnosis, their differential in why they were concerned, what they ordered or next steps in ordering, and what they told the patient. That way, they knew exactly what they were thinking and what was relayed to the patient.

See in medical school, they like things nice and neat. They want you to be complete, but don’t want things to be a mess. The way they taught us all the way up above at the start of this post makes things uniform. Especially since people in the first two years have varying degrees of previous exposure to writing notes.

HOWEVER, the internal medicine version I just mentioned is much more inclusive of everything. And as a scribe, it helped me lump in why we were doing things for which diagnosis. It also helped me learn some at home/plan things that were typically involved with each diagnosis. You start learning what labs, imaging, and at home changes the patient needs to do for what types of diagnoses. One, you learn which will always help you. Two, when you start hearing the spiel for the next patient or for patients down the line, you know where you are going to put that information in the chart and what diagnosis it should go with!

Now, this example probably wouldn’t be as well suited for an outpatient visit. So I’ll try another one in this format.

 1. Elevated blood pressure. Patient has had two office recordings of elevated blood pressures. This was discussed today in office. At this time, he does not meet criteria for HTN, however we have discussed obtaining a BP cuff for home, or going to a local CVS/Walgreens/Walmart to regularly check his pressures. If he obtains one for home, discussed having a nurse visit to make sure it is properly calibrated. If he is using a store, discussed the importance of using the same cuff from the same store to obtain accurate readings. We will review his readings upon his follow up visit. Behavioral modifications such as walking more, or starting more exercise/activity, increasing his water intake over sodas/teas/sugary drinks, and lowering his salt intake discussed and patient given high blood pressure handout. All questions/concerns addressed. 

2. Pre-diabetes. Patients Hemoglobin A1c in office today is 6. Diet versus medication discussed at length. Patient would like to trial behavioral and diet modifications first. Will see how this is going when he returns for his BP checkup, otherwise will obtain another A1c in 3 months. Side effects of metformin, dosing, and regimen discussed at length. Offered a referral to our in house nutritionist, which he would like to schedule a visit with. 

3. BMI of 31. Discussed importance of weight loss, which would help improve both his elevated BP and pre-diabetes. Healthy food choices and exercise/activity discussed. 

4. Smoking. Cessation discussed. Patient is not willing to quit at this time as he reports it "helps with stress". However he is willing to trial cutting back. Cessation assistance offered, he declined today.

As you can see, I set this one up for a really great future heart disease patient. But you will see a lot of people like this in clinic. The first bullet point is longer than I would have put; this is for your benefit so you can see what something may be talked about in clinic. In general, you would probably put less than that. As a new scribe though, there is nothing wrong with writing that down. Just don’t be sad when your provider erases a chunk of it, as it is implied in the notes that all those things were discussed.

What do you put in the plan versus the patient’s handout?

Great question! So glad you asked.

In general, a lot of what you will put in your plan versus the patient handout will be the same. The only differences are you will put more information of what was explicitly discussed in the patient’s handout and you will write it in layman’s terms. You will need to put all those details in there of making a nurse visit, suggesting for activity, suggestions for small changes discussed as there is usually a lot talked about in a doctors visit. Having all that written down will help the patient remember. This will get printed either by the physician or the front desk staff before they checkout and handed to them to take home.

PLUS, a lot of EMR’s now have pre-made handouts for different diseases. So you can search for the disease and what type of information you want to give the patient to have that printed out as well. For example, for pre-diabetes nutritional guide, you could find that instead of just a handout explaining what pre-diabetes is and why it’s concerning.

The plan will be a shorter, more concisely worded, and with more medical jargon put in place. The plan will be part of your SOAP note. The printout will be in the chart, but not part of the actual note itself that your doctor and other physicians will read. That is why they look at the plan!

I hope this was helpful in differentiating and how to write an A&P versus an MDM. Again, just like with your HPI’s, practice makes perfect. Thankfully though, a lot of this will either be directly dictated to you or discussed with the patient in the room, and you just have to jot down the information.

Good luck! Cheers.