Graduate Medical Education
2008 Housestaff Orientation: Informational Resources
Medical Decision Making
The third component of Evaluation and Management guidelines is medical decision making. There are four types of medical decision making: straightforward, low complexity, moderate complexity, and high complexity. The type of medical decision making is based on:
- the number of possible diagnoses and the number of management options to be considered
- the amount and/or complexity of medical record, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed
- the risk of significant complication, morbidity, and/or mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options (Buppert, 2000).
The table below (Table III) shows the elements required for each level of medical decision-making. Two of the three elements in the table must be either met or exceeded for each given type of decision-making.
Table III
Type of Decision Making |
Number of diagnoses or management options |
Amount and/or complexity of data to be reviewed |
Risk of complications and/or morbidity or mortality |
Straightforward |
Minimal |
Minimal |
Minimal |
Low Complexity |
Limited |
Limited |
Low |
Moderate Complexity |
Multiple |
Moderate |
Moderate |
High Complexity |
Extensive |
Extensive |
High |
There are many questions the healthcare provider must consider when assessing the level of risk. Since the determination of risk is complex, the following table (see Table IV) from Evaluation and Management guidelines is presented to give clinical examples. The highest level of risk in any one category determines the overall risk (Buppert, 2000). The clinical thought process of the healthcare provider must be documented in order for him/her to receive reimbursement. Documentation of the diagnosis and status of the diagnosis, treatment plan to include patient instructions, drugs, referrals, consultations, and follow-up is important. Documentation of tests ordered or reviewed, results interpreted, discussion of findings and intervention is required (Rapsilber & Anderson, 2000).
Table IV
Elements Required to Determine Risk Level |
Risk Level |
Presenting Problem |
Diagnostic Procedure |
Management Options |
Minimal |
- One self-limited or minor problem
|
- Lab test requiring venipuncture
- Chest x-rays
- EKG/EEG
- Urinalysis
- Ultrasound
- KOH prep
|
- Rest
- Gargles
- Elastic bandages
- Superficial dressings
|
Low |
- 2 or more self-limited or minor problems
- one stable chronic illness
- acute uncomplicated illness or injury
|
- Physiologic tests not under stress
- Non-cardiovascular imaging studies with contrast
- Superficial needle biopsies
- Clinical laboratory test requiring arterial puncture
- Skin biopsies
|
- Over the counter drugs
- Minor surgery with no identified risk factors
- Physical therapy
- Occupational therapy
- Intravenous fluids without additives
|
Moderate |
- One or more chronic illnesses with mild exacerbation, progression, or adverse effects of treatment
- Two or more stable chronic illnesses
- Undiagnosed new condition with uncertain prognosis, such as a lump in the breast
- Acute illness with systemic symptoms, such as pyelonephritis
- Acute complicated injury
|
- Physiologic test under stress
- Diagnostic endoscopies with no identified risk factors
- Cardiovascular imaging studies with contrast and no identified risk factors, such as an arteriogram
- Fluid obtained from a body cavity, such as a lumbar puncture
|
- Minor surgery with identified risk factors
- Elective major surgery with no identified risk factors
- Prescription drug management
- Therapeutic nuclear medicine
- Intravenous fluids with additives
- Closed treatment of fracture or dislocation without manipulation
|
High |
- One or more chronic illnesses with severe exacerbation, progression, or adverse treatment effects
- Acute or chronic illness or injuries that pose a threat to life or bodily function, such as acute MI
- An abrupt change in neurologic status, such as seizure
|
- Cardiovascular imaging studies with contrast
- Cardiac electrophysiological tests
- Diagnostic endoscopies with identified risk factors
|
- Elective major surgery with identified risk factors
- Major emergency surgery
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate or to de-escalate care because of poor prognosis
|
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