Classroom Training Review and Practice: Mdm

Classroom Training Review and Practice: MDM

During your last training days in the classroom, you were introduced to several aspects of the medical decision-making elements of the patient medical record, as well as some of the associated special documentation. Remember that the MDM serves to "paint the picture" of the patient's visit to the emergency department. You may like to think of the other areas of the medical chart as background, or baseline information, for the individual patient. The MDM then elaborates upon the course of the patient's condition as it evolves and changes in the ED. As it outlines the care provided to the patient, it is imperative that the medical record MDM be both complete and accurate. As a review, the MDM often includes, but is not limited to, the following:

* An indication that previous patient records have been reviewed.

* An indication that the patient's vital signs have been reviewed.

* The results of continuous vital monitoring: cardiac monitor, pulse oximetry, etc.

* The results of momentary monitoring: ECG/EKG, EEG.

* Any laboratory tests ordered, the results, and the physician interpretation.

* Any radiologic tests (X-rays, CT scan, MRI, Ultrasound, etc.) ordered, the results, and the physician interpretation.

* All procedures (ex: suturing, lumbar puncture, etc.), associated details, and patient response.

* All medications given and the patient response.

* All treatment given and the patient response.

* Any consultations conducted.

* Any counseling given to the patient.

* Differential diagnosis.

Each of the above items will be addressed in detail over the course of this section along with abbreviations and vocabulary that you will find useful in your documentation.

Review of Patient Records and Vital Signs

You will find that almost all medical record template systems will have an area dedicated to the review of previous medical records, current visit nursing notes, and current visit vital signs. When the physician reviews a chart before seeing a patient, he is consulting the nursing notes; a triage nurse evaluates each patient briefly before they are placed in an ED room. Additionally, the patient's attending nurse usually conducts his or her own history and physical exam, including vital signs, on the patient and documents this in the chart. Affirming that the physician has reviewed these notes is an easy data point to hit