Home Forums Discussions Recommendations for Amazing Charts Medical Decision Making (MDM)

Consider adding MDM next to the Plan at the bottom where this is:

Plan|CDS|Intrustions|Goals|Health concerns

I (just my way of doing things) rarely use Goals or Health Concerns and don't know what CDS is.

Medical Decision Making so:

Plan|MDM|CDS etc.

and have MDM under the Assessment box. Wouldn't necessarily need an entirely new field. Just if you select it, it puts it one line below your assessments:

Not sure about progress notes and consultation notes, but it ALL THE RAGE in ED notes. I guess they are forced to use them to explain what diagnoses they considered and why it could be or could not be. It is really helpful documentation.

Isn't CDS Clinical Decision Support?

Yes, it is but CDS (Clinical Decision Support) is documenting what you used to come to your conclusions, i.e. I used UpToDate as a source or even quoting it. It contains 5 rights: The right information, to the right person, in the right format, through the right channel, at the right time in the workflow.

It is not the same as MDM where you document what you were thinking and how you arrived at it. It tends to be used to validate or invalidate certain diagnoses.

Plus, if you bring up MDM, many physicians will know what it stands for and what it is where almost none will know what CDS is the acronym for.

This area needs to be discussed and flushed out how on how it should look and function. Let's do that! Remotely, and in person. Whose in?

In the meantime...

Upload sketches/images and/or videos explaining what you want for this area. Where you would want to see it, etc. STAT.

The MDM goes right after the assessment. In ED notes and some consult notes they have changed notes to APSO (assessment, plan, subjective, objective) it sucks.

Anyway, I did a note today with cramp pain and paresthesia and pain at the plantar fascia. Went with Vitamin B12. So I did Vitamin B12, IF, folate, etc.

On the MDM, I wrote more like considered autoimmune diseases, MS, other causes of paresthesia, etc. DVT unlikely due to know redness or warmth and a 13 year old in good health, playing sports and no smoking or contraceptives with no family history. If nothing else pans out, consider Doppler. Vitamin B12 can cause cramping, paresthesia, exquisite pain especially hands and feet, etc.

The MDM explains exactly what you were thinking and how you arrived at your diagnosis. Of course, you wouldn't use it for an ear infection.

The ED has a hard time not just writing the entire HPI in the MDM, a consequence of the APSO note.

It could be like a button that brings down the title for MDM. In most EDs now, it is required.

We call it the Differential Diagnosis. What you Ruled out. I have seen it as a click button in an EMR that is prepopulated from the diagnosis you choose.

I talked through this with some of providers in our practice. They totally dug it.

I am not clear what is being proposed... yes, we like to include a differential diagnosis in some notes. Call that MDM if you like.
Are you suggesting that AC include templates for this?
AI generated differentials?

What is the suggestion?

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.

Ok. So you want to put that into a note. It makes it a great note.
How are you proposing to change AC?

I would make the CDS tab a MDM tab and have it go under the plan and say:

Multiple Decision Making

I will share one of mine where I left off the MDM and got audited by an asshole ID specialist. I had a

5 month old female patient with normal exam but fever to 103. I would love to always do cathed urines but parents think you are torchuring them. So I did a bagged urine and the micro was >20,000. I wanted to do a cath on that but they refused so I treated with cefdinir to cover the usual E. coli. The culture grew two bacteria. Enterococcus and E. colo. So, I added amoxicillin. The E. coli did come back sensitive to amoxicillin but in Maine that is 50%.

My MDM should have been

Urine grew two pure bacteria, one of which is ALWAYS resistant to cephalosporins (the enterococcus) and E. coloi which is 50% of the time resistant to amox. So, I had started with cefidinir. Not having the C & S back, I knew the E. coli was covered by not the enterococcus in a bady with a 103 fever. So, I added cefdinir.

That would have covered me, yes a bagged urine is not great but if there are no contaminants then it is just as good. Yes amox would have covered both but I didn't know that at the time. So, the EXPERT ripped on "contamination" and two antibiotics (after the fact). Never got to talk to this expert who doesn't know how to manage UTIs. A cathed specimen wouldn't have changed anything unless there were five other bacteria growing.

Total side note - but we have really loved working with AIT/Healthtrax for UTI's - it's a PCR swab. We mail ours out via UPS everyday around 4:30 and have a full panel of results the following morning and it looks at antibiotic resistance. It's covered by insurance, and it's pretty slick. They are bridging with our AC soon so demos and insurance pull over. The do UTI, GI, Resp, etc etc.

Here are their panels: https://www.healthtrackrx.com/our-menus/

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We were literally just discussing how one of our providers LOVES to include MDM and the other one believes in 'chart as little as possible'. Guess which one we all prefer; including our specialist that we refer to. If you've got time to write MDM it goes so much context, and investigational fodder if the issues are recurrent. I love it. Not everyone will use it - but so be it. That's practice preferences.

Great comment. I know that our ED keeps adding more and more things to cover their ass, but it's ridiculous. Thins like:

Rapid strep antigen: positive
Rapid strep control: positive

But MDM is the best thing they have added. Plus I learn from what they were thinking. There is a double-edged sword. I had a patient go in with paresthsias of the left foot from a B12 deficiency, they went in for something else. In the MDM the doctor stated he didn't think it could be B12 because the other symptoms weren't present, i.e. macryocytic anemia.

I wanted to jump through the computer and ask him if a deficiency would necessarily present with every B12 problem at once, i.e. brain issues, etc.

We don't have a great way to have a dialogue with ED doctors which would be helpful although some get defensive if you email them.

I had one ED doctor write something to the effect that the PCP wrote for XXXX. Then opined I am not sure why he would use that....unfortunately the patient can't always recite MDM.

@Sabbath

Your info on AIT/Healthrax is so information and cool, I thought it needed its own thread. So, I started one for you (hope you don't mind) so users can ask about it.

https://acusersforum.com/ub/ubbthre...ew/1/ait-healthtrax-for-quick-diagnoses/

Thanks Bert! I expanded a bit over there. Happy to answer any questions.