Documentation Tips

Documentation Tips: Medical Decision Making

Documentation Tips: Medical Decision Making

Medical Decision Making is where the value of your work-up is defined and defended. MDM normally drives the level of care that can be reported. Document these components to support your higher levels of care.

MANAGEMENT OPTIONS: This includes the physician’s orders, decision to admit (transfer), consult with specialist. When you speak with another provider state what it was about, not just the provider’s name or specialty.


  1. The ordering and REVIEW of medical studies including lab tests, radiological and medicine tests such an ECG’s and echocardiograms.
  2. Discussion of results with the performing physician.
  3. Decision to obtain old medical records
  4. Review and SUMMARY of old records.
  5. Discussion of case with other health care providers (this includes psych evals., Medical Social Worker consults)
  6. Obtaining history from someone other than family
  7. VISUALIZATION (noted as “read by me personally”) of the x-ray image, EKG or monitor tracing or specimen, not just a review of the specialist’s report.


  1. One or more chronic illnesses with severe exacerbation
  2. Abrupt change in neurological status
  3. Acute or chronic illness that MAY pose a threat to life or bodily function (multiple trauma, respiratory distress / failure, psych. illness with potential threat to self / others, peritonitis, acute renal failure)
  4. Parenteral controlled substances
  5. Drug therapy requiring intensive monitoring for toxicity (IV Dilantin, Cardizem, Insulin)
  6. Decision to deescalate care / DNR

Differential diagnoses specific to the patient’s complaint and age as well as discussion of WHY a test wasn’t ordered is highly valued cognitive work and when it is documented. Meaningful differentials can make all the difference in coding certain cases. For payers your highest value resides in how treatment / management decisions were made, not just what was concluded. You must document your thought processes; i.e., 8 year old patient presents with a head injury with brief loss of consciousness and one episode of vomiting. The patient is now alert with minor headache; a head CT was discussed with the parents who declined due to the increased risk from exposure to excessive radiation as a child. Or, flu was the diagnosis but fever lead you to consider meningitis or pneumonia. This is cognitive work that could potentially increase the medical decision making from moderate to complex.


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