From the Guidelines
A comprehensive Medical Decision-Making (MDM) note should include the patient's presenting problem, data reviewed, risk assessment, and treatment plan, as supported by the most recent guidelines and studies, such as 1 and 1. Begin by summarizing the patient's chief complaint, relevant history, and current clinical status. Document all data reviewed, including lab results, imaging studies, prior records, and information from other providers. Clearly articulate your diagnostic reasoning, including differential diagnoses considered and why certain conditions were ruled in or out. Assess the level of risk based on the patient's condition, comorbidities, and potential complications, as outlined in studies such as 1 and 1. Detail your treatment plan with specific medications (including names, dosages, frequency, and duration), procedures recommended, referrals made, and follow-up instructions. Address any patient education provided and document informed consent discussions for high-risk interventions, as recommended by 1 and 1. Include your clinical judgment regarding the necessity of treatments and how you balanced risks and benefits. This comprehensive approach ensures continuity of care, supports medical necessity for billing purposes, and provides legal protection by demonstrating thorough clinical reasoning and appropriate standard of care. Some key elements to include in the MDM note are:
- Patient assessment, including medical history, physical examination, and testing, as outlined in 1
- Treatment plan, including medications, procedures, and referrals, as recommended by 1
- Risk assessment, including evaluation of comorbidities and potential complications, as supported by 1
- Patient education and informed consent discussions, as emphasized by 1 and 1
- Clinical judgment and decision-making process, including balancing risks and benefits, as highlighted by 1 and 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Comprehensive Medical Decision-Making (MDM) Note
A comprehensive MDM note should include the following elements:
- Patient history and presentation
- Diagnosis and treatment options
- Medication management and potential interactions
- Patient education and follow-up care
Key Components of an MDM Note
The note should document the following:
- The patient's chief complaint and history of present illness
- Relevant medical history, including allergies and medications
- Physical examination findings and laboratory results
- Assessment and plan, including diagnosis, treatment options, and patient education
- The note should also include any relevant citations or references to support the diagnosis and treatment plan, such as 2 which discusses the importance of patient-centered care in managing multiple chronic conditions.
Considerations for MDM Notes
When creating an MDM note, consider the following:
- The note should be clear, concise, and easily understandable by other healthcare providers
- It should include all relevant information, including laboratory results and medication lists
- The note should be regularly updated to reflect changes in the patient's condition and treatment plan, as discussed in 3 which outlines the importance of taking a comprehensive patient history.
- The use of standardized templates and checklists can help ensure that all necessary information is included, as seen in 4 which discusses the treatment of hypertension with lisinopril.
Additional Resources
For further information on creating comprehensive MDM notes, see: