Assessment and Plan sections form the clinical reasoning and management core of medical documentation. Yet writing comprehensive A/P for complex multi-problem patients consumes significant time during busy clinical days. According to medical documentation standards, A/P quality directly affects reimbursement—vague A/P lacking specific diagnosis codes, clinical reasoning, or management detail results in downcoded or denied claims.
What 5 Elements Must Every A/P Section Include?
Every quality A/P section includes 5 essential elements:
A/P Documentation Template
| # | Element | Purpose | Example |
|---|---|---|---|
| 1 | Working diagnosis | State the clinical impression | "Type 2 diabetes, poorly controlled" |
| 2 | Supporting data | Justify the assessment | "A1c 8.5% on metformin 1000mg BID" |
| 3 | Clinical reasoning | Explain the why | "Inadequate control requiring intensification" |
| 4 | Specific plan | Actionable next steps | "Add empagliflozin 10mg daily" |
| 5 | Follow-up | Monitoring and timeline | "Recheck A1c in 3 months" |
A/P Template by Problem Type
Copy these templates for common clinical scenarios:
Chronic Disease Management (Well-Controlled)
**Problem #1: Hypothyroidism** Assessment: Well-controlled on levothyroxine 75mcg daily. TSH 2.1 (normal). Plan: Continue current dose. Recheck TSH in 6 months.
Chronic Disease (Requires Adjustment)
**Problem #2: Hypertension** Assessment: 47-year-old woman with BP 165/95 despite lisinopril 20mg daily, suggesting inadequate control. Plan: 1) Increase lisinopril to 40mg daily 2) Add HCTZ 12.5mg daily 3) Low sodium diet counseling 4) Home BP monitoring 5) Recheck in 2 weeks; if still elevated, add amlodipine 5mg
Acute Problem with Diagnostic Uncertainty
**Problem #3: Chest pain** Assessment: Chest pain, likely musculoskeletal given reproducibility with palpation and absence of cardiac risk factors. However, atypical cardiac causes cannot be excluded given age and smoking history. Differential: 1) Musculoskeletal 2) GERD 3) Atypical ACS Plan: 1) ECG and troponin to exclude ACS 2) Trial of NSAIDs if cardiac workup negative 3) Return precautions for worsening symptoms
How to Structure Multi-Problem A/P Efficiently
Problem Organization by Priority
| Priority | Problem Type | Documentation Depth |
|---|---|---|
| 1 (First) | Acute, requiring intervention | Full assessment + detailed plan |
| 2 | Chronic, poorly controlled | Full assessment + adjustment plan |
| 3 | Chronic, stable | Brief assessment + continue plan |
| 4 (Last) | Health maintenance | Status + screening due |
For stable problems, use efficient documentation: "Problem 5: Hypothyroidism. Assessment: Well-controlled on levothyroxine 75mcg. Plan: Continue. Recheck TSH in 6 months." One line per stable problem prevents note bloat.
How to Document Clinical Reasoning
Explain why you chose specific management:
"Starting SGLT2 inhibitor empagliflozin for diabetes given patient's heart failure comorbidity. SGLT2 inhibitors provide cardiovascular mortality benefit in HFrEF per DAPA-HF trial."
Address why standard treatments were NOT used when applicable:
"Not starting ACE inhibitor despite heart failure diagnosis due to patient's history of angioedema with lisinopril. Will use ARB as alternative."
Document shared decision-making:
"Discussed options of medical management versus surgery for knee OA. Patient prefers trying conservative management first. Plan: PT referral, NSAID trial. Reassess in 3 months."
Billing and E&M Level Considerations
A/P Complexity and E&M Coding
| MDM Level | A/P Characteristics | Example |
|---|---|---|
| Straightforward | 1 minor problem, minimal risk | URI: supportive care |
| Low | 2+ minor or 1 chronic stable | HTN: continue meds |
| Moderate | 1+ chronic with mild exacerbation OR 1 undiagnosed new problem | DM with poor control |
| High | 1+ chronic with severe exacerbation OR acute threat to life | Chest pain r/o ACS |
Critical rule: Prescriptions, tests, and referrals ordered must appear in the plan. Orders without corresponding A/P documentation create compliance risk during audits.
Frequently Asked Questions About A/P Documentation
How many problems should I list?
Address all active problems, but prioritize by acuity. For patients with 10+ chronic conditions, you don't need full A/P for each. Stable conditions get one-line entries. Focus documentation depth on problems requiring clinical decision-making.
Should I include differential diagnosis in A/P?
Yes, when diagnosis is uncertain. "Differential: 1) Pneumonia 2) Bronchitis 3) Early CHF exacerbation" demonstrates thorough clinical thinking and justifies the workup ordered.
How specific should plans be?
Specific enough to execute without additional information. "Increase lisinopril to 40mg daily" is actionable. "Optimize antihypertensives" is vague and unhelpful for the next provider or for auditors.
What if my plan changes mid-visit?
Document the evolution. "Initially planned CT for abdominal pain, but given improvement with PPI and benign exam, will defer imaging and treat empirically for GERD. Return if worsening."
Can AI help write A/P sections?
Yes, AI tools like River's A/P Generator create structured problem-based A/P documentation. Input the diagnosis and clinical data, and the AI generates properly formatted A/P with assessment, plan, and follow-up. Always review and customize for specific patient circumstances.
AI assessment and plan generation creates well-structured problem-based A/P documentation that clinicians can customize for specific patients. Use River's A/P Generator to create numbered A/P paragraphs covering diagnostic assessment and management plans. Quality A/P documentation communicates clinical reasoning clearly while supporting appropriate reimbursement.