How to add MDM (Medical Decision Making)

DocVilla is designed primarily for outpatient medical practices and is not configured for Emergency Room (ER) or hospital-based workflows. As such, the platform follows the standard SOAP (Subjective, Objective, Assessment, Plan) format for clinical documentation.

We currently do not support separate sections for MDM (Medical Decision Making), Final Disposition, Diagnoses, or ACI. These components would need to be documented within the Assessment and Plan section of the SOAP note.

We understand that this may differ from more traditional ER charting, but aligning documentation within the SOAP format helps ensure consistency across outpatient settings using DocVilla.

In a SOAP note, Medical Decision Making (MDM) typically falls under the Assessment and Plan sections, depending on how detailed and structured your SOAP format is.  

A: Assessment

• Diagnosis(es) and your clinical impression. You can use the Diagnosis macro while creating templates.

• Here, the provider begins to synthesize the subjective and objective data.

• MDM starts to appear here in the form of diagnostic reasoning or differential diagnoses.

P: Plan

• Treatment strategy, labs/imaging orders, referrals, follow-up instructions.

• This is where Medical Decision Making is fully documented — it includes:

  • Rationale for chosen diagnosis/treatment

  • Risk/complexity of the problem(s)

  • Data reviewed or ordered

  • Consideration of alternatives

  • Communication and coordination of care