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General · Templates

Assessment & plan (AP) note template

For fast encounters where clinicians think in problems and plans first: a thin context layer, only the findings that matter, then a crisp Assessment & Plan—ideal when full SOAP narrative slows you down.

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Template content

Copy or download, then paste into Wavo under My Templates.

Assessment & Plan (AP) Note

Context (Brief)
- Visit type and one-line reason for visit.
- Only critical background that changes today’s decisions (key PMH, allergies, pregnancy status as relevant).

Pertinent Subjective / Objective
- 2–6 lines max: key symptoms, vitals, focused exam, and data reviewed that support the plan.
- Omit exhaustive ROS/exam negatives unless they change MDM.

Assessment & Plan
For each problem (numbered):
- Impression/status in one line.
- Plan: meds, diagnostics, education, referrals, work guidance, and follow-up.
- Controversies/shared decisions briefly if discussed.

Disposition
- Return precautions and next contact/visit.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Matches how many clinicians actually synthesize quick visits.
  • Keeps documentation short without dropping medical decision-making.
  • Problem-numbered A/P scales from one issue to a few.
  • Great Wavo target when the conversation is brief and plan-heavy.
  • 1Quick medication checks and results visits
  • 2Low-complexity same-day problems
  • 3Clinicians who prefer A/P-first charting

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Context
Telehealth med check for hypertension; also reviews fasting lipids.

Pertinent S/O
Home BP avg 138/84; adherent to amlodipine 5 mg. No chest pain/edema. BP today 142/86. LDL 142 on therapy? — not on statin yet.

A/P
1) Hypertension — above goal; increase amlodipine to 10 mg daily; home BP log; BMP in 2 weeks.
2) Hyperlipidemia — start atorvastatin 20 mg QHS after counseling on myalgias; fasting lipids in 12 weeks.
3) Health maintenance — due for tetanus booster; deferred to in-person visit.

Disposition
Message if SBP persistently >160, chest pain, or severe headache. Follow up 4 weeks (can be phone if BP improved).

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.

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