Which of the following is NOT typically included in the Plan?

Which of the following is NOT typically included in the Plan?

• A. Vitals
• B. Medications
• C. Education
• D. Referral

Answer: (A)

In notes, the Plan section is where you outline what you will do next for the patient—prescribing medications, ordering tests, arranging referrals, and providing patient education, along with follow-up plans. Vitals, on the other hand, are measurements taken during the visit and belong to the Objective portion of the note. They describe the patient’s current status and help inform decisions, but they aren’t actions to be carried out, so they aren’t typically listed in the Plan. Medications are a classic Plan item because you specify what to start, stop, or adjust. Education fits there too because you document what the patient needs to know and do after the visit. Referrals are clearly actions to arrange additional care or specialists. So, those three belong in the Plan, while vitals belong in the Objective as data that guide the plan. If vitals are referenced in the Plan, it’s usually only as a trigger or monitoring parameter, not as the action itself.

In notes, the Plan section is where you outline what you will do next for the patient—prescribing medications, ordering tests, arranging referrals, and providing patient education, along with follow-up plans. Vitals, on the other hand, are measurements taken during the visit and belong to the Objective portion of the note. They describe the patient’s current status and help inform decisions, but they aren’t actions to be carried out, so they aren’t typically listed in the Plan.

Medications are a classic Plan item because you specify what to start, stop, or adjust. Education fits there too because you document what the patient needs to know and do after the visit. Referrals are clearly actions to arrange additional care or specialists. So, those three belong in the Plan, while vitals belong in the Objective as data that guide the plan. If vitals are referenced in the Plan, it’s usually only as a trigger or monitoring parameter, not as the action itself.