Wiki plan of care

[igor]

Can a plan of care be documented in the HPI?
Example,
Mr. Smith has DM2
In the ER where we usually document the plan of care is blank
In the HPI under DM2 documentation state "stable on insulin" can we use this as a plan of care

 

[thomas7331]

A plan of care doesn't have to be in a particular section of a note, but "stable on insulin" is not a plan of care - it's an assessment of the patient's status.