From the Guidelines
Medical Decision Making (MDM) for charting should prioritize documenting the complexity of clinical decisions based on the number and complexity of problems addressed, data reviewed, and risk of complications, with a focus on patient-centered care and shared decision-making, as emphasized in the most recent study 1. When charting MDM, it is essential to consider the patient's care preferences, goals, and meaningful health outcomes, as outlined in the clinician's guide to geriatric assessment 1. This approach ensures that care aligns with what is important to the patient.
Key Components of MDM Documentation
- Clearly describe diagnostic reasoning, differential diagnoses considered, and treatment rationale
- Document specific medical problems addressed during the encounter, noting whether they are new, stable, worsening, or improving
- Include details about data reviewed, such as lab results, imaging studies, or previous records
- Explicitly state risk assessment and how it influenced the management plan
- Use specific language that demonstrates clinical judgment rather than vague statements ### Importance of Shared Decision-Making Shared decision-making is vital to patient-centered care, as it improves patients' understanding of treatment options, increases realistic expectations of benefits and harms, and stimulates engagement in decision-making, as noted in the 2023 AHA/ACC clinical performance and quality measures for coronary artery revascularization 2.
Aligning MDM Complexity with Patient Condition
The complexity of MDM (straightforward, low, moderate, or high) should align with the nature of the patient's condition and the decisions made during the encounter, taking into account the patient's baseline functional and cognitive status, chronic medical conditions, social determinants of health, and life expectancy, as discussed in the clinician's guide to geriatric assessment 1. By prioritizing patient-centered care and shared decision-making, and documenting the complexity of clinical decisions, healthcare providers can ensure that MDM for charting supports high-quality patient care and appropriate billing, as supported by the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease 3.
From the Research
MDM for Charting
- There is limited research directly related to MDM for charting, however, studies have explored the concept of Minimally Disruptive Medicine (MDM) in clinical practice 4.
- MDM aims to minimize the healthcare footprint and workload on patients, caregivers, clinicians, and health systems, which may be relevant to charting and patient assessment 4.
- History taking is a key component of patient assessment, enabling the delivery of high-quality care, and understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients' problems 5, 6.
- The use of MDM in clinical practice has been studied in the context of HIV care models, which may provide insights into the application of MDM in other areas, including charting 4.
- Other studies have focused on specific medical conditions, such as migraine and chronic myeloid leukemia, but do not directly address MDM for charting 7, 8.