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Properly Documenting Medical Decision Making

Here are just a few helpful tips for properly documenting MDM

    • List your impressions and differential diagnoses
    • Document review of current meds and medication reconciliation
    • Document medical care provided prior to patient’s arrival (e.g. EMS)
    • Note information obtained from sources other than the patient (parent, guardian, relative, caregiver, nursing home)

  • List all interventions and procedures, medications including route of administration, re-assessments, response to treatment, changes in status that may outweigh the presenting problem
  • Document pertinent details of discussions with PCP and/or consultants
  • Note pertinent contents of any old records reviewed
  • Document impression of ancillary test results
  • Record “per my review for EKG or imaging studies not formally interpreted
  • Record discharge instructions including medications, and follow-up
  • Give a definitive time frame for a phone or office follow-up
  • Document the diagnosis(es) and list all that are pertinent
  • Remember to note acute or emergent when applicable
  • Review Nurses Notes for accuracy in supporting orders, interventions, disposition

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