What Should Go in Your Medical Decision Making Section - A Few Principles to Guide You

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