Write assessment and plan (A/P)
AI creates numbered assessment and plan paragraphs organized by diagnosis, with clinical reasoning and specific management plans.
Write assessment and plan (A/P)
River's Assessment and Plan Generator creates organized A/P sections for medical documentation. You provide diagnoses and management plans, and the AI writes numbered assessment and plan paragraphs following problem-oriented format. Each diagnosis gets its own numbered section with clinical assessment (current status, severity, response to treatment) and specific plan (medications, tests, consultations, monitoring, disposition). The A/P demonstrates clinical reasoning and communicates management clearly. Perfect for residents documenting progress notes, hospitalists writing daily notes, physicians creating complete assessments, or any clinician needing well-organized A/P sections.
Unlike disorganized or incomplete assessments, this tool structures clinical thinking systematically by problem. Good A/P sections show your diagnostic reasoning, document evidence-based management decisions, communicate plans clearly to other providers, and create record of clinical thought process. The AI organizes information logically, includes relevant clinical details, and presents specific, actionable plans. When A/P sections are complete and well-organized, they improve care continuity and demonstrate sound medical decision-making.
This tool is perfect for medical residents learning clinical documentation, hospitalists managing multiple problems, attending physicians ensuring complete notes, or any clinician wanting organized assessment and plan sections. If your A/P sections lack organization or completeness, this creates professional clinical documentation. Use it for progress notes, admission notes, consultation notes, or any medical documentation requiring assessment and plan.
Writing Strong Assessments and Plans
Strong assessment and plan sections follow problem-oriented format: numbered by diagnosis from problem list, with assessment and plan for each problem. Assessment summarizes current status: is patient improving, stable, or worsening? What's the severity? How are they responding to treatment? What's your diagnostic confidence? Include relevant objective data (vital signs, lab values, exam findings) that support your assessment. Then state specific plan: what treatments will you continue, start, or stop? What tests do you need? What consultants? What's the monitoring plan? When will you reassess? Be specific and actionable.
For each problem, demonstrate clinical reasoning. Don't just list orders; explain your thinking. Why are you choosing this antibiotic? What are you monitoring and why? What will prompt you to escalate care? Example: 'Problem #1: Community-acquired pneumonia. Patient is improving with ceftriaxone and azithromycin. Fevers resolved, WBC trending down from 15 to 10, oxygen requirement decreased from 4L to 2L. Chest X-ray today shows slight improvement in RLL infiltrate. Assessment: Moderate CAP, responding appropriately to antibiotics. Plan: Continue ceftriaxone and azithromycin for planned 5-day course. Wean oxygen as tolerated. Repeat CXR if not continued improvement. Anticipate discharge in 24-48 hours if continued improvement.'
Organize A/P by priority and logical grouping. Address most acute or active problems first. Group related problems (type 2 diabetes and its complications might be discussed together). Be systematic so every problem gets addressed. Use template: '[Problem name]. [Current status/assessment]. [Clinical reasoning]. Plan: [Specific actions].' End with disposition/overall plan: continuing current management, transitioning to different level of care, discharge planning, follow-up arrangements. Complete A/P communicates your clinical thinking and ensures systematic, thorough care.
What You Get
Numbered assessment and plan by diagnosis
Clinical assessment with current status
Specific, actionable management plans
Evidence of clinical reasoning documented
Organized problem-oriented format
Professional medical documentation
How It Works
- 1Provide clinical informationShare diagnoses, current status, and management plans
- 2AI writes A/PCreates organized assessment and plan in 2-3 minutes
- 3Review and refineVerify accuracy, add patient-specific details
- 4Paste into noteCopy A/P into progress note or medical record
Frequently Asked Questions
How detailed should assessment and plan be?
Detailed enough to communicate your clinical thinking and document sound medical decision-making. Include current status, key objective findings, your assessment of severity/response, and specific plan. Don't just list orders without context. Show your reasoning. If you're choosing specific antibiotic, brief rationale helps (covering likely pathogens, adjusting for renal function, etc.). Balance thoroughness with efficiency. Complex problems warrant more detail. Stable chronic issues can be briefer.
Should I repeat information from earlier in the note?
Some repetition is appropriate if it supports your assessment. Refer to key vital signs, lab values, or exam findings that inform your assessment. You don't need to repeat entire HPI, but highlighting pertinent facts shows your clinical reasoning. Example: 'The patient remains febrile to 101.5°F today despite 48 hours of antibiotics. WBC increased from 12 to 15. Exam shows new crackles in right base. Assessment: Pneumonia not responding to current therapy, possible resistant organism.' This selective repetition clarifies your thinking.
How do I organize problems that are related?
You can group related problems under single numbered heading or address separately. For example, 'Problem #3: Type 2 diabetes mellitus with complications (nephropathy, neuropathy, retinopathy)' allows you to discuss related issues together. Alternatively, list separately if each requires distinct management discussion. Use whichever organization communicates most clearly. Consistency matters more than specific approach. Choose system and stick with it.
What about stable chronic conditions?
Address briefly but don't ignore. Show you considered them. Example: 'Problem #5: Hypertension. Stable, well-controlled on current regimen. BP 128/76 today. Plan: Continue lisinopril 20mg daily. No changes.' This shows you reviewed the problem and made conscious decision to continue current management. For very stable chronic issues on long problem lists, you might group: 'Problems #8-12: Chronic stable issues (hypothyroidism, GERD, osteoarthritis, BPH, vitamin D deficiency). Continue current management, no acute issues.' But address active problems thoroughly.
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