2.2.i Documenting: A PCDM Key Element

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One PCDM key element is to document the process each and every time one of the PCDM elements are addressed.

Document the discussion and plan of care that results from interprofessional shared decision making. This is done to communicate across the disciplines and to provide protection from legal challenge if care providers can demonstrate that choices were offered and reliable information was provided about the options (8). The documentation of a shared decision making conversation should include:

    1. the decision,
    2. the agreed upon course of action,
    3. the ongoing roles and responsibilities of each party, and
    4. the risk-sharing agreement between the providers.

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Journal_Icon.png Personal Reflection

Reflect on what you would write in a brief note following Serena’s conversation with Monica, the pediatrician. Use the documentation guide to help you structure your thoughts.