How to Write an Assessment and Plan (With a Worked Case)

The assessment and plan is where you stop collecting and commit. If you’re asking how to write an assessment and plan, this walks you through what to include, what to leave out, and how to be accountable on rounds.

It’s for MS3s, MS4s, and interns starting notes and presenting. You’ll get a clear structure, one worked case from a doctor-signed practice case, and the plan mistakes that hurt patients. Every case is written and signed off by a doctor.

This is educational, not instructions for real patients. No drug names or procedures here, use local protocols.

What goes in an assessment and plan?

An assessment and plan has three parts: a one-line patient summary, an assessment that states your working diagnosis with supporting findings and the key differentials you considered, and a plan written problem by problem, covering tests, monitoring, education, and follow-up. Clear, concise, and tied to what you’ve heard and seen.

If you’re asking how to write an assessment and plan, remember these are the last two SOAP sections, and the assessment is "a synthesis of subjective and objective information" that names the working diagnosis and frames a differential with concise, evidence-based reasoning.

The plan lists what you’ll do next for each problem or organ system. It should cover diagnostic testing, interventions you’re considering, what to monitor, the education you’ll give, and how and when you’ll follow up, all aligned with the assessment above.

Your A&P is only as strong as the story you took, so build it on a focused history first.

Start with a one-line summary that frames the problem

Your one-liner sets the stage for your assessment. Give the team just enough context to follow your argument, without turning the opener into advocacy for one diagnosis before you have shown your data.

Use three elements, then stop. Risk profile, duration, and syndrome. That is the Columbia template, and Columbia's one-liner guidance says include only key facts, keep the differential discussion for after problem identification, and avoid making the one-liner a closing argument so you do not anchor early.

There is a built-in tension. The one-liner frames your assessment, then the assessment is where you commit. Bring a few pertinent negatives only when they tighten the syndrome, and pick them deliberately, see choosing negatives on purpose.

On rounds, that sounds calm and spare. One sentence, named risks, a time course, and the syndrome in plain terms. The worked case comes later, so no long example here.

How do you write the assessment?

Name your single leading diagnosis, then cite the two or three findings that make it lead. After that, list the key differentials, each with one fact that keeps it alive or one that pushes it down. Finish by stating whether one problem explains everything or if there are coexisting issues.

Commit. Umbrella labels that name organ damage without the cause are weaker than disease level calls. In the worked case below, the decisive call is hemochromatosis; 'cirrhosis' is a partial umbrella that misses the inherited cause.

Build a tight set from first principles, see where the differential comes from.

Say whether one process ties it all together or you’re facing several problems, using the frame in one diagnosis or several.

1. Lead with the single disease most likely and two or three supporting findings.
2. Name one to three alternates, each with a single pro or con fact. No hedging.
3. State whether one process explains everything or coexisting problems fit better, and why.

Problem-based vs systems-based plans, and when each fits

You can organize the plan by problem, with a mini assessment and plan under each issue, or by organ system, moving head to toe across cardiovascular, pulmonary, renal, and so on. Both are standard.

In my experience, problem-based fits focused admissions or clinic visits with a few active issues. Systems-based tends to fit ICU or very complex patients with many active issues. Services and schools differ, and attendings have habits.

Problem-based risks missing cross-cutting items like disposition, prophylaxis, and goals-of-care if you do not name them as problems. Systems-based risks burying the main diagnosis and creating scattered micro-plans. What the attending hears matters, either a story per problem or a checklist-style tour.

Whichever you use, put the leading problem first.

Worked example: aching knuckles and fatigue in a 52-year-old man

Martin Whitfield, a 52-year-old accounts manager and fictional AI patient from a doctor-signed Diagnosica case, opened with, "My knuckles have been aching and I've felt worn out for months." The family history of iron overload, the loss of libido, and the new breathlessness with ankle swelling only surfaced when asked directly.

52-year-old Northern European man with low alcohol intake and a brother with iron overload, nine months of fatigue and 2nd to 3rd MCP hand pain, bronze-gray skin, new exertional dyspnea with evening ankle edema, sexual dysfunction, and HbA1c in the diabetic range.

The leading diagnosis is hereditary hemochromatosis, because the picture spans joints, skin, endocrine, liver, and possibly heart, with transferrin saturation about 72 percent and very high ferritin, a first-degree relative affected, and little alcohol. The hand X-ray pattern is centered on the 2nd and 3rd MCPs with hook-like osteophytes and chondrocalcinosis, which fits iron overload and drops crystal arthropathy. Mildly raised transaminases with preserved synthetic function sit better with iron than with alcohol-related liver disease in someone drinking only a few units a week, and MASLD moves down because the iron studies point elsewhere. Type 2 diabetes as a standalone label is less likely, given pancreatic iron can drive the HbA1c here. Calling it cirrhosis alone names the damage and misses the cause.

1. Suspected hereditary hemochromatosis: confirm with genetic testing as the high saturation prompts; MRI liver to quantify iron; refer to hepatology or gastroenterology; treat per local guideline.
2. New breathlessness on stairs and evening ankle swelling: echocardiogram promptly to look for iron-related cardiomyopathy; escalate if it worsens.
3. Liver disease, currently compensated (no jaundice, no vomiting blood, no black stools, no confusion): stage the fibrosis; if cirrhosis is confirmed, enroll in liver cancer surveillance ultrasound every six months.
4. Raised HbA1c in the diabetic range: likely part of the same process; manage per local guideline.
5. Low libido and erection trouble: endocrine review.
6. Family: genetic counseling, and screening offered to first-degree relatives, which answers his question about his children.

Normal CBC and thyroid tests belong in the note as results, not as problems.

Try a case Commit to a diagnosis and a plan on an AI patient case, then check your scorecard. Start a case

The plan mistakes that hurt patients

Anchoring. The case flags a trap, blaming alcohol or fatty liver while skipping transferrin saturation and ferritin. Cirrhosis names the liver injury, which is partly right, but it still misses the treatable inherited cause in hemochromatosis. Same disease, different label, see diseases hiding behind labels.

Treating the symptom, missing the cause. Treating the tiredness before checking iron studies, which the case flags as directly worsening iron overload, is how plans go wrong. Order the studies first. Then review the result before any symptomatic step.

Forgetting the family and the follow-up. Skipping genetic counseling or screening of first-degree relatives leaves the inherited piece unattended. Once cirrhosis is confirmed, missing liver cancer surveillance drops a safety net the case expects. It belongs in the plan as its own line.

One line per problem makes omissions visible fast. Name the problem, then add tests, monitoring, referrals, and surveillance if cirrhosis is present. If any box stays blank, close that gap before sign-out.

How to present your A&P out loud on rounds

Keep it tight and audible.

1. Start with the one-liner. State age, sex, chief concern, key comorbidities, current status in one sentence, and if you need the longer version see a full patient presentation.
2. Say your assessment. In one breath, say "I think this is X because A, B, C," give the unifying diagnosis and two or three key discriminators from history, labs or imaging, no hedging, then stop.
3. Give the differential. State the alternatives you kept and why each survives, one clause per item with the clincher that kept it alive and what would rule it in or out next.
4. Plan by problem. Lead with the main problem, then safety, then disposition; one line per problem for investigations, monitoring, consults, escalation triggers; if they ask why, the assessment you wrote is your answer; for cold questions, see when the attending quizzes you.

How to get better at A&P before you write real ones

Diagnosica doesn't grade notes or teach documentation. You talk or type to an AI patient in a video avatar, order investigations with results and imaging, commit to a diagnosis and plan, then get a scorecard with competency scores and teaching points, free tier included.

Before you submit, write a one-liner, assessment bullets, and plan items. Then compare to the scorecard's teaching points.

Every case is written and signed off by a doctor, so you practice with a consistent differential and teaching points. No billing checklists or templates to memorize.

Use the two-minute quick case daily. Five clues, guess after each, then a one-line teaching point.

"It doesn't give advice about real patients, and it's not a diagnostic system. Treat every output as educational."

Don't have any AI write your actual notes; attendings want your synthesis and you need the reps to get faster.

For pacing and time outside, see the wider clerkship year.

Educational use only. Not medical advice. AI-generated; verify clinically against primary sources.

Clinical review pending.

Commit first Practice committing before your first real note on an AI patient case, then review your scorecard. Practice now