MDM 2023
ED Notes are changing in 2023; big thank you to John Organick-Lee for putting together this dot phrase for us to use
NOTE: If copying this from the website into cerner you will lose formatting (bold and underline); if you download the word document, the formatting will remain
To add this dot phrase:
1. Open any patient's chart, open a note, click into any area where you can free-text/type (ex. click "Free Text" section of HPI, or click "Notes" in HPI to open a text box
2. Click on the smart phrase icon -
NOTE: If copying this from the website into cerner you will lose formatting (bold and underline); if you download the word document, the formatting will remain
To add this dot phrase:
1. Open any patient's chart, open a note, click into any area where you can free-text/type (ex. click "Free Text" section of HPI, or click "Notes" in HPI to open a text box
2. Click on the smart phrase icon -
3. Click the blue plus icon to make a new smart phrase and title it anything you want (".mdm2023"), copy and paste the text below (NOTE: you may need to manually bold and underline specific text if you want)
4. Save and close out of the smart phrase window, you should now be able to use the smart phrase by typing whatever title you gave it (".mdm2023")
4. Save and close out of the smart phrase window, you should now be able to use the smart phrase by typing whatever title you gave it (".mdm2023")
Use the below file to copy/paste into Cerner to keep the correct formatting for your dot phrase
| mdm2023_update_2.docx |
MDM 2023 - udpated 1/4/2023
Assessment/Plan: _
Subjective: _
Objective: _
ED Course: _
Number and Complexity of Problems Addressed
Acute problems: _
Chronic problems: _
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed
[_] History obtained from review of non-GW ED visit records
Summary: _
[_] History obtained from source other than patient
Summary: _
[_] Independent visualization and interpretation of imaging, tracing, or specimen
Interpretation of imaging: _
[_] Discuss the patient with another provider
Name and summary of discussion: _
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality
Summary: _
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making
Summary: _
[_] Shared decision-making regarding de-escalation of care
Summary: _
Subjective: _
Objective: _
ED Course: _
Number and Complexity of Problems Addressed
Acute problems: _
Chronic problems: _
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed
[_] History obtained from review of non-GW ED visit records
Summary: _
[_] History obtained from source other than patient
Summary: _
[_] Independent visualization and interpretation of imaging, tracing, or specimen
Interpretation of imaging: _
[_] Discuss the patient with another provider
Name and summary of discussion: _
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality
Summary: _
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making
Summary: _
[_] Shared decision-making regarding de-escalation of care
Summary: _
Explanation
Assessment/Plan: Put this dot phrase either at the bottom of the MDM section of the powernote or at the beginning of the "Reexamination/Reevaluation" section as free text. This should be a typical narrative form of an assessment/plan. It may or may not include a differential diagnosis, dependent on provider style
Subjective: HPI, ROS, review of outside records can go here
Objective: Physical exam goes here
ED Course: Timestamped re-evaluation can go here
Number and Complexity of Problems Addressed
Acute problems: Should include symptoms (chest pain, nausea, fever), acute problems (dehydration, PO intolerance), and chronic conditions which add complexity to MDM (e.g. HTN and HLD in chest pain workup)
Chronic problems: List of other conditions/diagnoses not addressed in current ED visit, if redundant with HPI then could remove
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed || Just need to check the box, continue to import orders and lab results under MDM section of power note
[_] History obtained from review of non-GW ED visit records || Any external record not from the GW ED. May include Epic, CRISP, transfer summary from OSH, discharge summary from prior GW hospitalization
Summary: Do not need to summarize if it has been addressed in HPI
[_] History obtained from source other than patient || Must summarize who and what, do not need to put in summary section if mentioned in HPI. Can include family/friend/witness of event (in person or over phone), EMS, law enforcement, PCP, nursing home manager, etc.
Summary: Do not need to summarize if it has been addressed in HPI
[_] Independent visualization and interpretation of imaging, tracing, or specimen || Includes interpretation of XRs, CTs, US, rhythm strips, does NOT include EKGs if separately billed from our interpretation. Must be an ACTIVE interpretation (e.g. should say "I personally reviewed and interpreted XR to show no evidence of pneumonia or pulmonary edema" rather than "XR shows…")
Interpretation of imaging: Sample dot phrase could say “I personally reviewed and interpreted _ to show _” || can include phrasing such as “Please refer to official attending radiology report for comprehensive read” if you have medicolegal concerns
[_] Discuss the patient with another provider || Must be an individual who is not an ED provider at GW. E.g. cardiology, hospitalist, pharmacist, case manager, etc.
Name and summary of discussion: Sample dot phrase could say “I discussed current management with _. They agree with current plan of care and will evaluate the patient.”
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality || Common ED examples of SDOH include undomiciled status/homelessness, unemployed, lack of insurance, substance abuse. It is not enough to say that the patients are experiencing challenging SDOH. You must acknowledge in your MDM how it might affect their condition and what you are doing to address it. For example, patient with asthma exacerbation with no albuterol inhaler due to lack of health insurance, you consulted SW, gave prescription for meds, referred to Medicaid office, referred to Unity Clinic, provided inhaler at bedside for the patient to take home, etc.
Summary: Good place to summarize how SDOH was addressed, can also put in your re-eval section if that's how you roll
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug || This can be EITHER starting a prescription-level medication in the ED (such as IV narcotic) OR addressing prescription level medications that the patient will be discharged with, such as abx for cystitis, increasing home dose of HCTZ, etc. An example of the SDM discussion may be discussing with parent of child who comes in with URI and saying that you explained with family that most URIs are viral and do not require antibiotics. That's right: you get credit for NOT prescribing something as well, but you need to show in the MDM that this was addressed during the visit.
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making || Using clinical decision tools to inform your management of patient care increases complexity and risk, and outlining this gives credit in the MDM. This can include HEART score, PECARN, Canadian C-spine rule, NEXUS, Wells, PERC, etc. And you get credit whether you decide to order the test/image or not.
Summary: No need to summarize if you mention it in your assessment/plan
[_] Shared decision-making regarding de-escalation of care || This includes making a patient DNR/DNI, describing conversation with cardiology team regarding admission and the team determining that the patient does not meet inpatient admission or observation criteria, or having a SDM conversation with the patient who ultimately decides they do not want to be admitted but instead manage their condition in the outpatient setting. Does not include leaving AMA
Summary: _
Subjective: HPI, ROS, review of outside records can go here
Objective: Physical exam goes here
ED Course: Timestamped re-evaluation can go here
Number and Complexity of Problems Addressed
Acute problems: Should include symptoms (chest pain, nausea, fever), acute problems (dehydration, PO intolerance), and chronic conditions which add complexity to MDM (e.g. HTN and HLD in chest pain workup)
Chronic problems: List of other conditions/diagnoses not addressed in current ED visit, if redundant with HPI then could remove
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed || Just need to check the box, continue to import orders and lab results under MDM section of power note
[_] History obtained from review of non-GW ED visit records || Any external record not from the GW ED. May include Epic, CRISP, transfer summary from OSH, discharge summary from prior GW hospitalization
Summary: Do not need to summarize if it has been addressed in HPI
[_] History obtained from source other than patient || Must summarize who and what, do not need to put in summary section if mentioned in HPI. Can include family/friend/witness of event (in person or over phone), EMS, law enforcement, PCP, nursing home manager, etc.
Summary: Do not need to summarize if it has been addressed in HPI
[_] Independent visualization and interpretation of imaging, tracing, or specimen || Includes interpretation of XRs, CTs, US, rhythm strips, does NOT include EKGs if separately billed from our interpretation. Must be an ACTIVE interpretation (e.g. should say "I personally reviewed and interpreted XR to show no evidence of pneumonia or pulmonary edema" rather than "XR shows…")
Interpretation of imaging: Sample dot phrase could say “I personally reviewed and interpreted _ to show _” || can include phrasing such as “Please refer to official attending radiology report for comprehensive read” if you have medicolegal concerns
[_] Discuss the patient with another provider || Must be an individual who is not an ED provider at GW. E.g. cardiology, hospitalist, pharmacist, case manager, etc.
Name and summary of discussion: Sample dot phrase could say “I discussed current management with _. They agree with current plan of care and will evaluate the patient.”
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality || Common ED examples of SDOH include undomiciled status/homelessness, unemployed, lack of insurance, substance abuse. It is not enough to say that the patients are experiencing challenging SDOH. You must acknowledge in your MDM how it might affect their condition and what you are doing to address it. For example, patient with asthma exacerbation with no albuterol inhaler due to lack of health insurance, you consulted SW, gave prescription for meds, referred to Medicaid office, referred to Unity Clinic, provided inhaler at bedside for the patient to take home, etc.
Summary: Good place to summarize how SDOH was addressed, can also put in your re-eval section if that's how you roll
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug || This can be EITHER starting a prescription-level medication in the ED (such as IV narcotic) OR addressing prescription level medications that the patient will be discharged with, such as abx for cystitis, increasing home dose of HCTZ, etc. An example of the SDM discussion may be discussing with parent of child who comes in with URI and saying that you explained with family that most URIs are viral and do not require antibiotics. That's right: you get credit for NOT prescribing something as well, but you need to show in the MDM that this was addressed during the visit.
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making || Using clinical decision tools to inform your management of patient care increases complexity and risk, and outlining this gives credit in the MDM. This can include HEART score, PECARN, Canadian C-spine rule, NEXUS, Wells, PERC, etc. And you get credit whether you decide to order the test/image or not.
Summary: No need to summarize if you mention it in your assessment/plan
[_] Shared decision-making regarding de-escalation of care || This includes making a patient DNR/DNI, describing conversation with cardiology team regarding admission and the team determining that the patient does not meet inpatient admission or observation criteria, or having a SDM conversation with the patient who ultimately decides they do not want to be admitted but instead manage their condition in the outpatient setting. Does not include leaving AMA
Summary: _
Changes from last version (highlighted in red)
Assessment/Plan: _
Subjective: _
Objective: _
ED Course: _
Number and Complexity of Problems Addressed
Acute problems: _
Chronic problems: _
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed
[_] History obtained from review of non-GW ED visit records
Summary: _
[_] History obtained from source other than patient
Summary: _
[_] Independent visualization and interpretation of imaging, tracing, or specimen
Interpretation of imaging: _
[_] Discuss the patient with another provider
Name and summary of discussion: _
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality
Summary: _
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making
Summary: _
[_] Shared decision-making regarding de-escalation of care
Summary: _
Subjective: _
Objective: _
ED Course: _
Number and Complexity of Problems Addressed
Acute problems: _
Chronic problems: _
Amount and/or Complexity of Data Reviewed
[_] Labs ordered and reviewed
[_] History obtained from review of non-GW ED visit records
Summary: _
[_] History obtained from source other than patient
Summary: _
[_] Independent visualization and interpretation of imaging, tracing, or specimen
Interpretation of imaging: _
[_] Discuss the patient with another provider
Name and summary of discussion: _
Risk of Significant Complications, Morbidity, and/or Mortality
[_] Social determinants of health (SDOH) that may increase risk of significant complications, morbidity, and/or mortality
Summary: _
[_] Prescription drug initiation/management or shared decision-making discussion regarding prescription drug
Summary: _
[_] Evidence-based clinical decision tool used in medical decision making
Summary: _
[_] Shared decision-making regarding de-escalation of care
Summary: _
other dot phrases
Interpretation
CT images were reviewed and independently interpreted by me as _
XR images were reviewed and independently interpreted by me as _
POCUS images were reviewed and independently by me as _
I personally reviewed the patient’s cardiac telemetry and independently interpreted it as _
I personally reviewed the patient’s pulse oximetry which was _% on _, which I interpret as _
Consultant
I discussed current management with _. They agree with current plan of care and will evaluate the patient.
I discussed outpatient and/or emergency department medication management with our pharmacist.
Critical from radiology
I reviewed and discussed critical imaging with the radiologist regarding a finding of _
Admission
I reviewed the patient’s case, pending results and initial impression, with _, who agrees with plan of care and accepts
the patient for admission.
Non-clinical source
I contacted _ to discuss the management of the patient.
Admission considered but discharged
I considered hospitalization but the patient was ultimately discharged because _
De-escalation of care
The decision was made to de-escalate care or to not resuscitate based on poor prognosis. This decision was made
with _
SDOH
Diagnosis or treatment was significantly limited by social determinants of health.
Considered a test but didn’t do
I considered _ but did not because _
External records
I personally reviewed external records from _
CT images were reviewed and independently interpreted by me as _
XR images were reviewed and independently interpreted by me as _
POCUS images were reviewed and independently by me as _
I personally reviewed the patient’s cardiac telemetry and independently interpreted it as _
I personally reviewed the patient’s pulse oximetry which was _% on _, which I interpret as _
Consultant
I discussed current management with _. They agree with current plan of care and will evaluate the patient.
I discussed outpatient and/or emergency department medication management with our pharmacist.
Critical from radiology
I reviewed and discussed critical imaging with the radiologist regarding a finding of _
Admission
I reviewed the patient’s case, pending results and initial impression, with _, who agrees with plan of care and accepts
the patient for admission.
Non-clinical source
I contacted _ to discuss the management of the patient.
Admission considered but discharged
I considered hospitalization but the patient was ultimately discharged because _
De-escalation of care
The decision was made to de-escalate care or to not resuscitate based on poor prognosis. This decision was made
with _
SDOH
Diagnosis or treatment was significantly limited by social determinants of health.
Considered a test but didn’t do
I considered _ but did not because _
External records
I personally reviewed external records from _