Which item is typically included in the Plan section?

Which item is typically included in the Plan section?

• A. Antibiotics prescribed for 7 days
• B. Fever of 102 on arrival
• C. Cough heard on auscultation
• D. Patient's vital signs

Answer: (A)

In documentation, the Plan section records what will be done to manage the patient, including medications, orders, and follow-up. An antibiotic prescribed for seven days fits this because it is a concrete treatment decision with a defined duration—that’s exactly the kind of action the Plan captures. The other items describe what was found during the visit (fever on arrival, a cough heard on exam, vital signs) and belong in the assessment or objective portions, since they reflect the current state rather than the plan for treatment.

In documentation, the Plan section records what will be done to manage the patient, including medications, orders, and follow-up. An antibiotic prescribed for seven days fits this because it is a concrete treatment decision with a defined duration—that’s exactly the kind of action the Plan captures. The other items describe what was found during the visit (fever on arrival, a cough heard on exam, vital signs) and belong in the assessment or objective portions, since they reflect the current state rather than the plan for treatment.