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Assessment and Plan From Your Notes
Turn a problem list and plan fragments into a numbered assessment and plan, one problem at a time, with your reasoning and decisions intact.
River's assessment and plan writer turns your problem list and plan fragments into a numbered, problem-oriented assessment and plan. Each problem gets its current status, the findings that support it, and the plan you stated: what continues, starts or stops, what is being monitored, and what would change course. The most active problems come first and stable ones are kept brief.
The clinical decisions stay yours. It does not add a test, a drug, a dose or a consultation you did not write, and it does not invent reasoning you did not express. What it adds is order and clear sentences, plus a short list of any problem that has no plan and any plan item that is not tied to a problem.
This is for residents and hospitalists writing daily notes, and for anyone whose plan lives in fragments at the bottom of a note.
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.
How it works
Paste your notes
Your problem list, today's findings and the plan fragments, shorthand included, identifiers removed if needed.
Get the assessment
A numbered assessment and plan in plain text, ready to paste into the note.
Check the gaps
Review the problems without a plan, then ask for a shorter or longer version.
What you get
- Numbered assessment and plan by problem, most active problems first
- Status and supporting findings for each problem, taken from your notes
- Your plan written out in full sentences, with nothing added to it
- A short list of problems without a plan, and plan items without a problem
Common 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.
Can I paste real patient details?
Follow your organization's policy first. If your organization has a business associate agreement with River, work within its terms. If not, remove names, record numbers, addresses, exact dates and other identifiers before pasting. The assessment and plan rarely needs a name, so it is easy to leave them out.
Assessment and Plan From Your Notes
Describe what you need, add any files you have, and your workspace opens with the work already underway.