The world of medical informatics can be tricky. For example,
physicians are often called upon to write physician’s notes and plans of care.
However, there’s a very fine line between these two different things. Include
one thing in your note, and you’ve suddenly got a plan of care. Leave one thing
out, and you only have a physician’s note. In order to make sure you’re
actually creating what you want to create, it’s important to be able to
distinguish between the two.
In order to be considered a plan of care, the physician’s
note must include:
l Clinical
decisions about treatment
l Diagnosis
l Long-term
treatment goals
l Type
and frequency of services
l Medications
l Tests
Without one or any of these things, a note is just a note.
Tread carefully to ensure you only establish a plan of care when you actually
mean to.
If you are a healthcare clinician, are you using todays new healthcare app for Medical Decision Making, DeductorMD?
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