Concise Documentation of the Assessment and Plan

I asked Cedric Skillon, MD to write this post to elaborate on his method of documenting elements of the treatment plan. Dr. Skillon and I work in the same system of care. Over the years I have been impressed with the high quality of his work and a lot of that is captured in how the treatment plan is documented. I think his documentation is concise and yet it covers a lot of ground in terms of the clinical discussion with the patient and his thought process. What follows a discussion of his approach and a good example.  The remainder of this post was written by Dr. Skillon.   Fell free to add comments on what you find useful as concise documentation.

George Dawson, MD, DFAPA


Assessment and Recommendation/Plan

Throughout my medical education I was reminded over and over again to document everything that occurred during an appointment; because if it was not documented, it did not happen. But just as important, during my psychiatry residency training at Western Psychiatric Institute and Clinic, Dr. Petronilla Vaulx-Smith expressed upon me the fact that with every medical note that I write, any physician should be able to read my note, understand my logic, and be able to pick up taking care of that client from the last note that I wrote. Over the years my notes have evolved to include the following.

Assessment: In this section of the note I have 1-2 sentences to highlight sign/symptom changes that I have documented in greater detail in the History of Present Illness section of my note.

Recommendations/Plan: In this section I document medication and therapies prescribed, as well as the target symptoms for the medication or therapies that I am recommending. I also educate the patient about potential side effects and medication interactions with the prescribed medications. I then numerically list each step of the plan for that appointment, including medications prescribed and discontinued. With each prescription I state how long the prescription will last and if there was a refill included. I list continued therapies, including community support such as attending AA meetings.

Below is a fictitious example of an Assessment and Recommendation/Plan.

Assessment: Patient reports worsening depressive and anxiety symptoms. Patient has maintained his sobriety.


Recommendation/Plan: Plan to discontinue Wellbutrin XL. Plan to continue with current dose of Prozac. Plan to start Effexor XR in combination therapy with Prozac to treat depressive and anxiety symptoms. The patient will continue with individual psychotherapy and continue attending AA meetings. I educated patient about the risk of serotonin syndrome with the combination of Effexor XR and Prozac. I educated the patient about the symptoms of serotonin syndrome.


1. Patient was educated about the above assessment and plan.

2. Patient was educated about the side effects and potential benefits of each prescribed medication.

3. Patient gave verbal informed consent for the prescribed medications.

4. Discontinue Wellbutrin XL

5. Start Effexor XR 75mg take one pill daily. I gave patient a written prescription for a 30 day supply and no refills.

6. Continue with current dose of Prozac. On 12/20/16, I gave patient a written prescription for a 30 day supply and 5 refills)

7. Patient will continue with individual psychotherapy.

8. Patient will continue attending AA meetings.

9. Patient will schedule a follow up appointment to see Dr. Skillon in 2 weeks.

10. Patient agrees to call readily with questions, side effects, or clinical worsening. Patient agrees to call Dr. Skillon, or go to the closest emergency room if he has onset of suicidal ideation or homicidal ideation.

11. Treatment plan was discussed at length including alternative medications and importance of compliance.

Cedric Skillon, MD




Attributions:

Graphic at the top is from Shutterstock per their licensing agreement - "Medical files on a shelf" by Val Lawless.