A common question that comes from many clinicians from
trainees to seasoned attendings is:
“What do I put in my
medical decision making section?”
If you ask 10 different clinicians, you will likely get 10
different answers. There is no, one, standard method for making a medical
decision making/assessment and plan section. However, we can rely on a few
principles for guidance on how to make a reasonable and logical medical
decision making section.
Keep in mind your diagnosis(es) from the beginning of
your chart.
Your MDM section is where you pull everything together. You
must lay out the groundwork in the other parts of the chart first. Start
thinking about your MDM section long before that actual section in your chart
starts.
The details of the patients’ history and physical exam are
important. These details come in the form of pertinent positives and pertinent
negatives.
For example, if your assessment is that the patient has
bruising to the extremity and not a fracture, be sure specific details that support
your conclusion are in your history and physical. These can include details
such as:
- no point tenderness
- minimal swelling
- full range of motion with minimal pain
- mild tenderness
- diffuse tenderness
Focus on what you think the diagnosis(es) is
The remaining diagnosis(es) from your original differential
should be the focus on your chart. As above, support this conclusion with
details you have gathered. If you have done this, you can just put down your
diagnosis without further explanation.
You can simply write something such as “Findings are
suspicious for pulmonary embolism” and that should be all you need if the rest
of your chart includes details like
- recent 10 hour plane flight
- left leg swelling
- pleuritic chest pain
- feels anxious
- tachycardic
Minimize how much you list other diagnoses you have
already determined are low-probability
In the MDM section, I often read lengthy lists and explanations
as to why several diagnoses are not present. Proving the low probability of
another diagnosis is the job of the preceding sections of the chart. Repeating
what you have already said is unnecessary.
Demonstrate that during your investigations to get to your final
diagnosis(es), you checked on a few details to consider alternate diagnoses.
For example, when you already have a compelling story for another diagnosis, you
would not need to mention pulmonary embolism if you have already included
details such as:
- no tachycardia
- no leg swelling
- no OCP use
- no recent surgery
Spell out your plan based on your diagnoses.
Often I have seen clinicians list diagnoses and then their
described plans veer off in a completely different direction. It is as if they
are now addressing an unmentioned diagnosis.
Keep your plan consistent with your diagnosis. If you state
something inconsistent with your stated diagnoses, you should consider changing
your stated diagnosis, or question whether you really want to do what you state
that you plan.
For example, if you have listed pulmonary embolism and
costochondritis as your remaining differential diagnoses and then also order
blood cultures, you should amend your differential diagnosis to include
whatever infection you are assessing for.
If you’re interested in learning more about this or similar
topics, check out my book: The
Handbook of Medical Charting
