Where do you document or recommend documenting medical decision making and/or plan in eCW?
We currently document in the treatment section notes but have found this to be confusing for patients as it is published to the portal free-floating under the allergies section or in the other view under “instructions”.
We thought we could fix the problem by educating providers to document in the clinical notes section (as this does not publish) however after my IT team spoke with eCW we were told that we should expect that this will eventually publish to the portal as well (in an anticipated bug :l ).
Our last thought is that we document MDM in the Assessment section but this seems to move forward in the chart and follow the diagnosis.
Where are we supposed to document medical decision making?
I hope my signature works, its my first post.
Kelly Watson, Medical Informatics Specialist & Physician Assistant
Planned Parenthood of Orange and San Bernardino Counties (PPOSBC)
~70 providers
Family Planning & Primary Care
Version 10e