What components are essential for an ER Medical Decision Making (MDM) template?

Essential Components for an ER Medical Decision Making (MDM) Template

An effective Emergency Room Medical Decision Making template should include structured documentation of patient assessment, clinical reasoning, and care planning with clear documentation of medical necessity to support clinical decisions. 1

Core Documentation Components

Patient Assessment

• Document thorough clinical and laboratory evaluation, including appropriate cardiac imaging (ECG, echocardiogram, etc.) when indicated 1
• Include assessment of functional impairment in different domains (home, work, school) 2
• Document cardiovascular risk factors, immunization status, and substance use assessment (alcohol, tobacco, other substances) 2
• Complete medication reconciliation (current medications, dosages, adherence) and review of allergies and adverse reactions 2
• Record vital signs, height, weight, and BMI calculation as essential components 2

Medical Decision Making Elements

• Document the complexity of medical decision making based on:
  • Number of diagnoses or management options considered 1
  • Amount and/or complexity of data reviewed 1
  • Risk of significant complications, morbidity, or mortality 1
• Include explicit documentation of clinical reasoning that led to final diagnosis or differential diagnoses 1
• Document risk stratification for relevant conditions (e.g., chest pain categorization as noncardiac, atypical, stable angina, variant, unstable angina/NSTEMI, or acute STEMI) 1

Treatment Planning

• Document specific, measurable goals in key areas of patient functioning 2
• Include development of action plans based on achievable patient goals 2
• Document treatment plan that prioritizes goals and outlines intervention strategies 2
• Include medication management plan and lifestyle modification recommendations 2
• Document patient education on medication instructions and recognition of worsening symptoms 2

Disposition and Follow-up

• Document clear disposition decision (admit, discharge, transfer, observation) with clinical rationale 1
• Include follow-up plan with specific timeframe 2
• Document issues requiring monitoring before next visit 2
• Include referrals to specialists or allied health professionals as needed 2

Template Design Best Practices

Structural Considerations

• Use structured templates to ensure comprehensive documentation 2, 3
• Balance structured data entry with narrative information 2, 3
• Design template to minimize documentation burden while capturing essential information 2, 4
• Include integration of decision support tools when available 2
• Implement dynamic links that automatically populate the note with data documented elsewhere in the EMR to reduce redundant documentation 4

Clinical Content Optimization

• Organize template to follow clinical workflow 3, 5
• Include discrete data pick lists to replace free text where appropriate 3, 4
• Ensure template design allows for efficient documentation of medical necessity 1, 4
• Structure clinical templates for optimum use to reduce data entry time 3
• Include sections for documenting shared decision-making with patients 1

Implementation Considerations

Quality and Efficiency

• Design template to support quality metrics tracking relevant to patient conditions 2
• Optimize template to save time for direct patient care (studies show well-designed templates can save up to 23 minutes per patient encounter) 4
• Ensure template supports standardized data collection for research and quality improvement 6, 7
• Include semantic annotations where possible to improve data interoperability 7
• Regularly update templates based on changing guidelines and evidence 2

Common Pitfalls to Avoid

• Avoid excessive copy-paste functionality that can lead to note bloat and inaccuracies 3, 4
• Prevent over-templating that discourages documentation of unique patient presentations 3
• Ensure template doesn't force documentation of irrelevant information 3, 4
• Avoid templates that are too rigid and don't allow for documentation of atypical presentations 5
• Prevent templates from becoming so complex that they increase rather than decrease documentation time 4