Clinical Reasoning Assessment and Plan

Now that you have gained your patient's trust, gathered a detailed history, and completed the requisite portions of the physical examination, you have reached the critical step of formulating your Assessment(s) and Plan. It is your task to analyze your findings and identify the patient's problems. Furthermore, you must share your impressions with the patient, eliciting any concerns and making sure that he or she understands and agrees to the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format. A clear and well-organized record is essential for communicating the patient's story and your clinical reasoning and plan to other members of the health care team.

The comprehensive data you have collected, both subjective (the history, or what the patient or family have told you) and objective (the physical examination and laboratory tests), make up the core elements of your patient's database. This information is primarily factual and descriptive. As you move to Assessment, you go beyond description and observation to analysis and interpretation. You select and cluster relevant pieces of information, analyze their possible meanings, and try to explain them logically using principles of biopsychosocial and biomedical science. The Assessment and Plan include the patient's responses to the problems identified and to your diagnostic and therapeutic plans. A successful Plan requires good interpersonal skills and sensitivity to the patient's goals, economic means, competing responsibilities, and family structure and dynamics.

In this chapter, we describe the process of clinical reasoning and illustrate the written Assessment and Plan using the case of Mrs. N from Chapter 1, pp. 14-18. A series of guidelines outline principles for developing an accurate, clear, and logical patient record. A well-organized record facilitates clinical thinking, promotes communication and coordination among the many professionals caring for your patient, and documents that patient's problems and management for medicolegal purposes. There is also a section describing quantitative tools such as sensitivity and specificity to help strengthen your skills of clinical reasoning.

Generating Your Assessment. Because assessment takes place in the clinician's mind, the process of clinical reasoning often seems inaccessible

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