Can this app grade the level of Medical Decision Making (MDM) in a progress note?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: November 21, 2025View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Can This App Grade Medical Decision Making in Progress Notes?

No, the evidence provided does not support that any existing app can grade the level of Medical Decision Making (MDM) in clinical progress notes.

Current State of Health App Capabilities

The available evidence focuses exclusively on health apps designed for:

  • Patient self-management of chronic diseases 1
  • Symptom tracking and monitoring 1
  • Mental health interventions 1
  • Contact tracing 1
  • Patient education 1

None of the reviewed literature addresses apps capable of analyzing clinical documentation or evaluating the complexity of medical decision-making in provider notes 1.

What Health Apps Actually Do

The evidence demonstrates that current health apps primarily:

  • Enable patient-provider communication through bilateral messaging systems 1
  • Track patient-reported outcomes using standardized questionnaires like PHQ-9 for depression or disease-specific indices 1
  • Monitor physiological data from wearable devices (heart rate, steps, oxygen saturation) 1
  • Provide automated feedback based on entered symptoms or vital signs 1
  • Send reminders for medication adherence and appointments 1

App Evaluation Tools vs. Clinical Documentation Analysis

While app evaluation frameworks exist—such as the Mobile App Rating Scale (MARS) 1, the American Psychiatric Association's evaluation model 2, and THESIS 3—these tools assess app quality dimensions including:

  • Engagement and usability 1, 4
  • Privacy and security 3
  • Clinical foundation and evidence base 2
  • Interoperability 3
  • Information accuracy 1

These frameworks evaluate the apps themselves, not clinical documentation content 3, 2, 5.

Critical Gap in Evidence

The systematic reviews examined hundreds of health apps across multiple therapeutic areas 1, yet:

  • No apps were identified that analyze provider documentation 1
  • No apps assess MDM complexity according to billing/coding criteria [1 through 5]
  • Medical calculation apps that were studied focused on clinical scores (liver disease severity, pulmonary embolism likelihood), not documentation analysis 1

Important Caveats

Accuracy concerns exist even for simpler app functions. When 14 medical calculation apps were evaluated, 98.6% of calculations were accurate, but some errors were clinically significant, and responsibility for adverse consequences falls on the individual clinician 1. This underscores that even basic medical apps require rigorous validation.

Lack of regulation remains problematic. The NHS has certified only 13 apps as "safe and secure" despite thousands available 1. Most health apps lack peer-reviewed clinical outcomes data or regulatory clearance 1.

Clinical Bottom Line

If you are seeking an app to evaluate MDM levels in progress notes for billing, quality assurance, or educational purposes, no validated tool currently exists in the published literature [1 through 5]. Any such functionality would require:

  • Natural language processing capabilities not described in current health app literature [1 through 5]
  • Validation against established MDM criteria (E/M coding guidelines)
  • Regulatory oversight given the clinical and financial implications

The question you're asking addresses a fundamentally different use case than what current health apps provide.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.