Primary Diagnosis and ICD-10 code: Also include any procedural codes.
3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.
Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?
Therapeutic modalities: pharmacological and nonpharmacological management.
Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
Patient education: Explanations and advice given to patient and family members.
Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist or therapist.
References (minimum of 3, timely, that prove this plan follows current standard of care).”