What should be included in a medical decision making template for an intern in the emergency department?

Comprehensive Medical Decision Making Template for Emergency Department Interns

A well-structured medical decision making (MDM) template is essential for organizing your clinical reasoning, documenting appropriate care, and ensuring optimal patient outcomes in the emergency department. The following template incorporates key elements from critical care medicine guidelines and emergency medicine best practices 1.

Chief Complaint

• Document the patient's primary complaint in their own words
• Include duration of symptoms

History of Present Illness (HPI)

• Onset: When did symptoms begin? Sudden or gradual?
• Location: Where is the problem? Does it radiate?
• Duration: How long has it been present?
• Characteristics: Quality, severity (1-10 scale)
• Aggravating/alleviating factors: What makes it better/worse?
• Related symptoms: Associated symptoms
• Timing: Constant, intermittent, progressive?
• Context: What was patient doing when it started?
• Modifying factors: What has the patient tried for relief?

Past Medical History

• Chronic conditions
• Previous hospitalizations/surgeries
• Current medications (prescription, OTC, supplements)
• Allergies and reactions
• Immunization status (relevant to complaint)

Risk Stratification

For geriatric patients, include screening questions 1:

• Need for assistance before illness/injury
• Increased help needed since illness/injury
• Hospitalizations in past six months
• Vision problems
• Memory problems
• Multiple medications (>3 daily)

Physical Examination

• Vital signs with interpretation
• General appearance
• Focused exam based on chief complaint
• Pertinent positive and negative findings

Diagnostic Studies

• Laboratory tests ordered with clinical rationale
• Imaging studies ordered with clinical rationale
• Point-of-care testing results
• Interpretation of results

Medical Decision Making

1. Problem Assessment

• List all active problems in order of priority
• For each problem:
  • Differential diagnosis (most likely to least likely)
  • Supporting evidence from history, exam, and diagnostics
  • Risk factors for serious conditions

2. Diagnostic Reasoning

• Document your clinical reasoning process
• Explain why certain diagnoses were considered or excluded
• Highlight key diagnostic uncertainties 2
• Document how diagnostic uncertainty was addressed

3. Risk Assessment

• Severity of illness/injury
• Risk of deterioration
• Risk of morbidity/mortality without treatment
• Consideration of social determinants affecting outcomes

4. Treatment Plan

• Interventions performed in ED
• Medications administered (dose, route, timing)
• Response to treatments
• Consultations obtained
• Shared decision-making discussion 1, 3:
  • Options presented to patient
  • Risks and benefits explained
  • Patient values and preferences elicited
  • Final decision and rationale

Disposition Decision

• Admission vs. discharge rationale
• If admitted: level of care needed and why
• If discharged: follow-up plan, return precautions
• Patient education provided

Reassessments

• Document all reassessments
• Changes in condition
• Response to interventions
• Updates to plan based on new information

Communication

• Document discussions with patients/families
• Document discussions with consultants
• Document discussions with primary care providers

MDM Complexity Documentation

Clearly document elements that justify your MDM complexity level:

• Low Complexity:

  • Limited data reviewed
  • Straightforward decision-making
  • Minimal risk

• Moderate Complexity:

  • Multiple data sources reviewed
  • Multiple diagnoses considered
  • Moderate risk of complications

• High Complexity:

  • Extensive data review (including outside records)
  • Extensive differential diagnosis
  • High risk of complications or death
  • Complex decision-making with multiple variables

Implementation Tips

1. Use this template as a framework but adapt to each patient
2. Document in real-time when possible
3. Clearly articulate your clinical reasoning
4. Include time stamps for critical interventions and reassessments
5. Document shared decision-making conversations thoroughly 1, 3
6. Use the template to ensure you don't miss critical elements

Common Pitfalls to Avoid

• Failing to document your clinical reasoning process
• Incomplete documentation of risk assessments
• Inadequate documentation of shared decision-making
• Missing documentation of reassessments
• Failing to document discussions with consultants
• Inadequate documentation of discharge planning
• Not addressing diagnostic uncertainty explicitly 2

This template emphasizes structured clinical reasoning, shared decision-making, and comprehensive documentation that supports both optimal patient care and appropriate billing/coding requirements. By consistently using this approach, you'll develop strong habits that will serve you throughout your emergency medicine career.