MDM Flashcards
MDM
Medical Decision Making
- summary of what happened during a patient’s visit and how that led the provider through the chart
- JUSTIFICATION of WHY they believe the patient is here today and what is being done to treat it
- culmination of subjective + objective info, support physician diagnosis, discuss how problem is being addressed
- one of most important parts of medical chart
Chief Complaint: Why is the patient here?
Differential Diagnosis (DDx):
- What was investigated and how?
- Discuss history, lab, and procedure findings.
- How did this rule out certain diagnoses?
- Discuss why the physician chose a certain diagnosis.
Final Diagnosis: What is the final diagnosis?
Treatment: What will the treatment be?
MDM:
- Responses to treatment
- Reviewing results
- Discussing disposition and treatment plans
Include consultations, Re-evaluation, Discharge, Procedure-laceration repair
Consultation- calling specialist
- Timestamp
- Full name of consultant
- Specialty service
- Recommendations ie admit to hospital, discharge
Re-evaluation
- Timestamp
- current general status- resting, in pain, hungry
- Status of CC- is it worse? did it get resolved? no change?
- new complaints
Discharge
- Specific symptoms as guidelines for Pt to return
- Follow up- w/ who, when, for what
- Medicolegal- express that Pt is aware and explained everything (ex- write “Pt verbally indicates understanding”)
Procedure-Laceration Repair
- length of laceration (one note for each laceration)
- location on body
- Anesthesia (ex- 4 cc of 1% Lidocaine or Marcaine w/ epinephrine for local anesthesia)
- Description- shape: linear, stellate/star shape, irregular, flapo
- Contamination
Case Summary
The Case Summary
Sometimes your physician will dictate a summary note that explains their thought process and reasons that directed the patient’s care in the facility. Essentially, they give you a statement detailing why they think what they think. This will support the diagnosis and plan.
This note is extremely important as provides a glimpse into the physician’s reasoning.
Ex- “The patients is a 65-year-old female with a history of hypertension, coronary artery disease, and smoking who presented to the emergency room with complaints of pressure-like, left-sided chest pain that began suddenly approximately 2 hours prior to arrival.
The patient’s chest pain was associated with palpitations, shortness of breath, and nausea, but the patient denied radiation of pain, back pain, or vomiting. Her pain was improved with 3mg of nitroglycerin given here in the ED, and her 12 lead EKG did not indicate any acute cardiac syndrome. The chest x-ray did not reveal any pneumothorax or pneumonia; her D-dimer was negative; and the two sets of cardiac enzymes were also negative.
However, given the patient’s significant history, the patient will be admitted for further cardiac workup and evaluation. I discussed the findings with the patient and her family, who are agreeable with the plan. Dr. Warren (the cardiologist on call today) also agrees to follow up with the patient.”
-Write which doc said this
-explains reasoning and thought process of physician
HIPAA
Health Insurance Portability & Accountability Act
-confidential patient health info (right to privacy)
- If Pt is not assigned to your doctor, do not touch their chart
- Don’t click anything you shouldn’t, your username is your fingerprint
- Never share your username or pw
- Don’t take pics
- Don’t write info on social media
- Don’t access your family, friend, or own chart- need permission
- Don’t store PHI on non-approved systems like Google Docs
PHI
protected health info
- first or last name
- DOB (date of birth)
- SSN (social security #)
- acct #s
- medical records
- lab results
- phone #s
- address
- images
- dates related to Pt
HITECH
Health Information Technology for Economic and Clinical Health Act
-privacy issues w/ electronic transmission of health info
HITECH states that PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption
Differential diagnosis
Best guess of what is going on w/ patient
Syncope
temporary loss of consciousness by fall in BP
emphysema
breathlessness b/c of enlarged alveoli
Pulmonary fibrosis
scarring
COPD
- exposed to pollutants (ie smoking) which means you lose lung elasticity = incomplete exhalation CO2 and wastes are left in body
- harm alveoli = emphysema
- chronic bronchitis
CF
-thickening tissue and mucus buildup
