From the Guidelines
The key components of a Medical Decision-Making (MDM) note include a comprehensive medical evaluation and assessment of comorbidities, as outlined in the standards of medical care in diabetes-2022 1. The MDM note should cover various aspects such as diabetes history, family history, personal history of complications and common comorbidities, high blood pressure or abnormal lipids, macrovascular and microvascular complications, and hypoglycemia awareness. According to the standards of medical care in diabetes-2022 1, the note should also include:
- Interval history, including changes in medical or family history since the last visit
- Eating patterns and weight history, including assessment of familiarity with carbohydrate counting
- Physical activity and sleep behaviors
- Tobacco, alcohol, and substance use
- Current medication regimen, including medication-taking behavior and potential intolerance or side effects
- Complementary and alternative medicine use
- Vaccination history and needs
- Technology use, including the use of health apps, online education, and patient portals
- Glucose monitoring results and data use
- Review of insulin pump settings and use, connected pen, and glucose data
- Social network, including existing social supports, surrogate decision maker, advanced care plan, and social determinants of health. A comprehensive MDM note should document clinical reasoning that supports diagnostic and treatment decisions, showing how the provider integrated patient information, test results, and medical knowledge to reach conclusions, as supported by the standards of medical care in diabetes-2022 1.
From the Research
Key Components of a Medical Decision-Making (MDM) Note
- A comprehensive patient history is fundamental for the accurate diagnosis and effective management of health conditions 2
- History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2
- Important communication skills for nurses when history taking include active listening, empathetic communication, and cultural sensitivity 2
- The decision to initiate certain medical interventions, such as dialysis, is best made through shared decision-making 3
- Controlling blood pressure and volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in patients with end-stage renal disease 3
Patient Assessment and History Taking
- History taking is a key component of patient assessment, enabling the delivery of high-quality care 4
- Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients' problems 4
- Care priorities can be identified and the most appropriate interventions commenced to optimize patient outcomes 4
- Taking a comprehensive health history is a core competency of the advanced nursing role, allowing the nurse and patient to establish a therapeutic relationship 5
Medical Management and Decision-Making
- Medical decision-making involves considering various factors, including patient history, physical assessments, laboratory investigations, and medical complications associated with certain conditions 3
- Nurses play a crucial role in medical decision-making, and their history-taking skills are essential for informing diagnosis and treatment 2, 4, 5
- Reflective practice, including reflection on history-taking skills, can enhance clinical practice and improve patient outcomes 5