MEDICAL DECISION MAKING

Visit type: [Office new or established, hospital inpatient or observation, emergency department, nursing facility, or home]
Level chosen by: [MDM, or total time on the date of the encounter where the visit type allows it]

PROBLEMS ADDRESSED
Problem 1: [Diagnosis or symptom, its status today, and what you evaluated or treated]
Problem 2: [Diagnosis or symptom, its status today, and what you evaluated or treated]
Status against goal: [At goal, not at goal, worsening, severe, or a threat to life or bodily function, with the finding that shows it]
Noted, not addressed: [Conditions another clinician manages that you did not assess today]

DATA REVIEWED AND ANALYZED
Tests ordered: [Each unique test, and the result that would change the plan]
Results reviewed: [Each unique test result with its date, and what it means for this patient]
External records: [Each outside source reviewed, with its date and the key finding]
Independent historian: [Who gave the history, and why the patient could not give a complete or reliable one]
Independent interpretation: [Your own read of an ECG, image, or tracing that another clinician will report]
Discussion of management: [Who you spoke with outside your group or specialty, when, and what you decided together]

RISK OF PATIENT MANAGEMENT
Decisions made: [Medications started, changed, continued, or stopped; procedures; tests; the level of care]
Options considered, not chosen: [What you discussed and decided against, and why]
Social determinants: [Housing, food, cost, or transport problems that limit the diagnosis or treatment, and how]

MDM LEVEL
Problems: [Minimal, low, moderate, or high]
Data: [Minimal or none, limited, moderate, or extensive]
Risk: [Minimal, low, moderate, or high]
Level: [Straightforward, low, moderate, or high, and the two elements that set it]
Total time, if used instead: [Minutes on the date of the encounter, and what they covered]

Signed: [Clinician name, credentials, date and time]