Medical decision making or MDM (usually after the assessment and either before or after the plan is defined as:
THE PROCESS BY WHICH A DIAGNOSIS OR TREATMENT PLAN IS FORMULATED FROM THE AVAILABLE INFORMATION:
So in the ED, you encounter an infant almost two months old with a temperature of 100.8. He appears well, and you do CBC with diff CRP, blood cultures and a urinalysis. His CRP comes back 2.2 which is elevated, perform an LP and CBC, urinalysis and micro are normal with blood cultures pending. An LP is negative. Due to cough and clear runny nose you obtain a positive RSV. The algorithm states you can admit with parenteral antibiotics or may observe closely in the hospital or at home. The parents seem dependable and live within 15 minutes of the hospital with reliable transportation. They prefer to take the child home. You discharge the baby with close follow-up with the PCP. They are to return to the ED or call PCP for worsening symptoms (which you explain).
Here the ED doctor could take the conservative route or discharge home with close f/u. He sends the child home. Now he needs to explain his thinking:
Medical Decision Making: Keeping it short:
Patient did meet criteria for admission or discharge to home. The infant looked good and HAD A SOURCE FOR THE FEVER AND INCREASED IM (RSV). The baby was not having increased respiratory findings and was satting 98% in room air. The parents are reliable, live closely and have transportation. Based on the positive RSV, I felt comfortable sending home with close f/u and monitoring the LP and urine culture and blood cultures. I called the PCP for f/u agreement and planned to call the child the following morning.
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You wouldn't necessarily do an MDM for an ear infection, but here you could go either way with a possible E. coli or other bacteremia. But you have explained your thinking which makes sense, is documented for any review, and reminds you in six months why you did what you did.
Notice I didn't go into detail with a differential diagnosis such as:
Meningitis
Sepsis
Pneumonia
Too many ED reports just state the same thing in the MDM as the HPI and say what they did with no reasoning behind it.
Last edited by Bert; 03/16/2024 7:17 PM.
