What’s in your MDM?

[deleted836128]

For the record I am an ER PA, practicing two and a half years. Trying to get faster and more efficient and one thing I have noted is that my medical decision making sections of my charts are often redundant and possibly overly detailed, stating info again that was relayed in the HPI or PE. It’s an obsessive habit I have; however my charting just feels crappy to me if I don’t do this exact format. Here’s an example of what my typical MDM would look like.

Ms. Smith is a 62 year old female with a history of diabetes who presented to the emergency department today with left lower abdominal pain and nausea for three days. She denies fevers or vomiting. On examination she was well appearing and in no distress with vitals remarkable only for an elevated blood pressure. There was mild left lower quadrant tenderness without guarding or rebound tenderness. Blood work revealed no leukocytosis. Urinalysis indicated 2+ bacteria without elevation in white cells, nitrite or leukocyte esterase. CT of the abdomen and pelvis with intravenous contrast showed acute sigmoid diverticulitis without abscess. Incidentally Ms. Smith had a cyst on the left kidney which I informed her about; she understands she needs to see her primary care doctor for further evaluation. She was given a liter of normal saline with morphine and odansetron, and on re-evaluation symptoms were much improved. Repeat abdominal examination was benign and she was tolerant of oral fluids. At this point I feel discharge is appropriate. I prescribed metronidazole and ciprofloxaxin, and advised close follow up with primary care. I urged her to return to the emergency department if new or worsening symptoms like fevers or intractable pain. She was discharged in stable condition with her husband taking her home.

Redundant right? This would be a shorter MDM for me. If the case is not so slam dunk I might go into more of my differentials and why I felt Ms Smith does not need further testing.

I get compliments regularly for my thorough and detailed and relatively type free charts so I hate to change things up too dramatically. Anyone have suggestions for me on MDM?

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[deleted836128]

I should mention that my attendings all have very bare bones MDMs. Theirs literally might say with the above case: Patients CT showed diverticulitis. Given antibiotics and recommended PCP a follow up.

I don’t want to be that bare bones but also want a decent chart!

 

[USCDiver]

I should mention that my attendings all have very bare bones MDMs. Theirs literally might say with the above case: Patients CT showed diverticulitis. Given antibiotics and recommended PCP a follow up.

I don’t want to be that bare bones but also want a decent chart!

First, you misspelled “typo” in the OP !

Second, why not be bare bones on a straightforward case? I’m assuming anyone reading your note has access to the lab and imaging reports too. How long does it take you to recap the whole chart like the example in your OP?

 

[alpinism]

Take out all the HPI, PMH, and PE info above which is redundant and unnecessary.

Example: Patient presenting with abdominal pain and nausea. I'm concerned for x,y, and z. Labs showed x,y, and z. Imaging showed x,y, and z.

Patient was given interventions. Upon reevaluation patient reported resolution of symptoms.

Add on discharge instructions and boom you're finished.

 

[gro2001]

For the record I am an ER PA, practicing two and a half years. Trying to get faster and more efficient and one thing I have noted is that my medical decision making sections of my charts are often redundant and possibly overly detailed, stating info again that was relayed in the HPI or PE. It’s an obsessive habit I have; however my charting just feels crappy to me if I don’t do this exact format. Here’s an example of what my typical MDM would look like.

Ms. Smith is a 62 year old female with a history of diabetes who presented to the emergency department today with left lower abdominal pain and nausea for three days. She denies fevers or vomiting. On examination she was well appearing and in no distress with vitals remarkable only for an elevated blood pressure. There was mild left lower quadrant tenderness without guarding or rebound tenderness. Blood work revealed no leukocytosis. Urinalysis indicated 2+ bacteria without elevation in white cells, nitrite or leukocyte esterase. CT of the abdomen and pelvis with intravenous contrast showed acute sigmoid diverticulitis without abscess. Incidentally Ms. Smith had a cyst on the left kidney which I informed her about; she understands she needs to see her primary care doctor for further evaluation. She was given a liter of normal saline with morphine and odansetron, and on re-evaluation symptoms were much improved. Repeat abdominal examination was benign and she was tolerant of oral fluids. At this point I feel discharge is appropriate. I prescribed metronidazole and ciprofloxaxin, and advised close follow up with primary care. I urged her to return to the emergency department if new or worsening symptoms like fevers or intractable pain. She was discharged in stable condition with her husband taking her home.

Redundant right? This would be a shorter MDM for me. If the case is not so slam dunk I might go into more of my differentials and why I felt Ms Smith does not need further testing.

I get compliments regularly for my thorough and detailed and relatively type free charts so I hate to change things up too dramatically. Anyone have suggestions for me on MDM?

Think about the chart from the perspective of someone reviewing it 6 months later after a complaint or a bad outcome. All the stuff that was done they can gleam from their own reading of the orders and results. What they won't be able to figure out is what your thought process was. Thats why I think its super important to include your differential and why you didn't pursue certain diagnoses. From your note it seems like the only thing on your radar was diverticulitis. Perhaps with the straightforward case described above it might be unnecessary, but consider the very typical scenario of basically the same case but the CT does not actually given a specific diagnosis, instead reads something like "nonspecific bowel loop thickening, correlate clinically". I would write something along the lines of:

"62 yo F, PMH DM, presented with abdominal pain. Workup other than non specific CT findings and mild leukocytosis were unremarkable. Given the presentation, benign exam and brief observation in ER, not concerned for significant intrabdominal pahtology like appendicitis, mesenteric ischemia, or SBO. Not concerned for nephrolithiasis. Care instructions and strict return precautions given. Will follow up with PMD in 2 days"

That way even if she bounces back with a missed diagnosis, it shows that you considered a wide range of possibilities but it just did not seem to fit the case.

 

[Birdstrike]

Good news: We have much better people running medicare now, with the current administration. They're finally, FINALLY, at least considering reducing the ridiculous amount of red tape that has been heaped on us, for so long, regarding documentation. Medicare may do away with this billing scheme based on MDM. And EM codes may get a boost.

Brace for a big shake-up to E/M coding. CMS announced its intention to pursue “comprehensive reform of E/M documentation guidelines” in the 2018 proposed Medicare physician fee schedule released July 13...“As long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam,” states the agency....Some potentially misvalued codes may get a boost. CMS is wondering whether to review emergency department visits (99281-99385) as undervalued “given the increased acuity of the patient population and the heterogeneity” of ED locations, such as free-standing and off-campus emergency departments.

Part B News | CMS may overhaul E/M coding; history (and exam) may ...

Also, "Includes many provisions aimed at easing provider paperwork burden"

2019 Proposed Medicare Fee Schedule Announced


Promising signs, but very early, and not yet final.

cc: @ERCAT

 

[Brigade4Radiant]

I make charting to the point and put the results in and one sentence MDM and say I engaged in shared decision making. It really doesn't help you to put in your thought in a paragraph on why your medical decision making is sending a patient home. Someone is reviewing your chart because your patient had a bad outcome and that happens.

Your entire note tells the story so if you send someone home without a CT scan don't but tenderness on your belly exam because that can be used against you. An Illinois EM doc put like a paragraph for MDM decision making but was taken to court and argued that patient had a murmur on exam and the doctor testifying against him stated that murmur was an acute murmur so a stat echo should have been ordered.

I don't do nurse charting in my note anymore like Patient ambulated at 7:15 with a steady gait because your nurse should be charting that. Also if the nurse charts something a miss and you don't that can be used to hurt you regardless of what you document in your note because it can be argued that that the nurse spends more time with the patient.

 

[southerndoc]

Obtain CT to rule out appendicitis, right-sided diverticulitis, or Crohn's/enteritis. No history of alcohol consumption to suggest pancreatitis. No hematuria to suggest ureteral colic. No pulsating mass to suggest AAA. No RUQ tenderness to suggest biliary etiology. CBC for rule out leukocytosis/anemia, iSTAT BMP to rule out renal failure or electrolyte abnormality. If CT negative or consistent with renal/ureteral involvement, will obtain UA. Pain meds, IV fluids.

[time]: CT consistent with acute appendicitis without evidence of perforation or complication. Surgery consulted. Antibiotics given. On reevaluation, the patient's pain has improved.

OR

[time]: CT without acute abnormality. On reassessment, patient's pain has improved. Labs essentially normal. Will refer to PCP for follow-up. Levsin SL (or whatever) for pain. Patient instructed to return for repeat examination if pain continues >24 hours or if condition warrants. Patient agreeable with plan and seems to understand plan. Questions answered.

 

[Apollyon]

A classmate from residency was sued (and lost) for not giving "broad enough" spectrum antibiotics. I would humbly suggest that the abx be named (Unasyn 3.1gv I given, per surgeon request, Ancef 1gIM, Cipro/Flagyl, that sort).

 

[deleted859535]

A classmate from residency was sued (and lost) for not giving "broad enough" spectrum antibiotics. I would humbly suggest that the abx be named (Unasyn 3.1gv I given, per surgeon request, Ancef 1gIM, Cipro/Flagyl, that sort).

Can you share what the diagnosis was and the antibiotic given?

 

[Apollyon]

If I recall, it was ceftriaxone, when they argued Zosyn or better. But, I think Rocephin was the thing (there was a bigger picture thing going on there, where a cardiologist put in way too many unnecessary stents).

 

[deleted859535]

If I recall, it was ceftriaxone, when they argued Zosyn or better. But, I think Rocephin was the thing (there was a bigger picture thing going on there, where a cardiologist put in way too many unnecessary stents).

Oy. Dunno about the stents part, but at least tell me this antibiotic suit business happened in Illinois or some not-doc-friendly state.

 

[Apollyon]

Maryland

 

[turkeyjerky]

A classmate from residency was sued (and lost) for not giving "broad enough" spectrum antibiotics. I would humbly suggest that the abx be named (Unasyn 3.1gv I given, per surgeon request, Ancef 1gIM, Cipro/Flagyl, that sort).

The name of the antibiotic ordered will easily be seen on the orders or prescription list, likewise there's no need to quote the lab results or imaging findings on your MDM, but you do need to discuss the significance of said findings.

In the OPs case, which sounds very straightforward, nearly no MDM is really needed. I would probably write: pt presents w/ abs pain, clinically c/w diverticulitis--confirmed on CT. Stable for output managemt, discussed return precautions.

My dc instructions, also written in the chart would include typical return precautions as well as a recommendation so see PMD within 2-3 days and to discuss an outpatient colonoscopy in 4-6 weeks.

Charting for the same patient would've much more detailed if I forgoed the CT and treated empirically.

My general philosophy is that you need to justify the tests you did not order, rather than the testing you did do.

 

[Apollyon]

The name of the antibiotic ordered will easily be seen on the orders or prescription list, likewise there's no need to quote the lab results or imaging findings on your MDM, but you do need to discuss the significance of said findings.

In the OPs case, which sounds very straightforward, nearly no MDM is really needed. I would probably write: pt presents w/ abs pain, clinically c/w diverticulitis--confirmed on CT. Stable for output managemt, discussed return precautions.

My dc instructions, also written in the chart would include typical return precautions as well as a recommendation so see PMD within 2-3 days and to discuss an outpatient colonoscopy in 4-6 weeks.

Charting for the same patient would've much more detailed if I forgoed the CT and treated empirically.

My general philosophy is that you need to justify the tests you did not order, rather than the testing you did do.

I don't trust anyone else to keep things so well documented. I hear what you are saying, but, I believe, more information is better than less.

 

[engineeredout]

I have an MDM on all my charts, even if it is a simple case. "35 YO m presents for suture removal from left arm. Wound is well healing, sutures removed, patient to follow up with PCP".

Then on the more complex cases I'm not just trying to recap, I'm trying to explain my thought process and the course of events during the emergency department. While yes this may come up in a future legal proceeding, I also look at it from the perspective of the inpatient team who is trying to figure out what happened with the patient, why they got admitted, and what lead to us choosing our course of action.

 

[RoyBasch]

[time]: CT consistent with acute appendicitis without evidence of perforation or complication. Surgery consulted. Antibiotics given. On reevaluation, the patient's pain has improved.

OR

[time]: CT without acute abnormality. On reassessment, patient's pain has improved. Labs essentially normal. Will refer to PCP for follow-up. Levsin SL (or whatever) for pain. Patient instructed to return for repeat examination if pain continues >24 hours or if condition warrants. Patient agreeable with plan and seems to understand plan. Questions answered.

Pretty much this. I try to avoid any kind of subjectivity in the MDM. I don't really see the point in re-stating things that are already covered in the history and exam.

I do use the MDM to document any kind of "unusual" situation not immediately obvious to someone reading the chart such as patient signing out AMA or declining a test the H&P seem to support. I will document shared decision making conversations. I also document that I informed the patient specifically of their return precautions, follow up plan, and the importance of follow up.

Sometimes I will use the MDM to explain some incongruence like an imaging finding not supported by clinical exam (eg. CT shows "cystitis" but UA is negative, pt has no urinary symptoms, and CT was ordered to evaluate for pancreatic pseudocyst or something, therefore UTI not suspected and not treated...)

On resuscitations/critical patients I will give a very brief play-by-play of the resuscitative events and rationale (why was the patient intubated, why were pressors started, etc.)

 

[RoyBasch]

Charting for the same patient would've much more detailed if I forgoed the CT and treated empirically.

My general philosophy is that you need to justify the tests you did not order, rather than the testing you did do.

agree, ironically I think more stuff you have clearly done for the patient, the less you really need to explain. If testing supported by the H&P is not done, I think this should be explained in the MDM.

 

[hundreddaysoff]

Obtain CT to rule out appendicitis, right-sided diverticulitis, or Crohn's/enteritis. No history of alcohol consumption to suggest pancreatitis. No hematuria to suggest ureteral colic. No pulsating mass to suggest AAA. No RUQ tenderness to suggest biliary etiology. CBC for rule out leukocytosis/anemia, iSTAT BMP to rule out renal failure or electrolyte abnormality. If CT negative or consistent with renal/ureteral involvement, will obtain UA. Pain meds, IV fluids.

[time]: CT consistent with acute appendicitis without evidence of perforation or complication. Surgery consulted. Antibiotics given. On reevaluation, the patient's pain has improved.

OR

[time]: CT without acute abnormality. On reassessment, patient's pain has improved. Labs essentially normal. Will refer to PCP for follow-up. Levsin SL (or whatever) for pain. Patient instructed to return for repeat examination if pain continues >24 hours or if condition warrants. Patient agreeable with plan and seems to understand plan. Questions answered.

I've heard multiple malpractice and reimbursement experts agree w/ this style of frequent timestamps and it seems like a relatively bulletproof style. But I don't have a scribe and due to the slowness of charting w/ Meditech and need to multitask, most of my charting is done after my shift when I'm not gonna remember all the times that all the things happened within 2h or so. Immediately editing MDM after a timestamp-able thing happened seems both unrealistic and super-annoying.

So, how do you chart in this style on the ground? Do you write down times for important things as they happen? Do you use timestamps for reassessment and time you viewed results on every single chart regardless of complexity?

Somewhat relatedly: from a billing perspective, how important is it that my documented discharge/admit times are (1) accurate and (2) consistent w/ times written by other providers? Trying to remember and awkwardly click-in these times in Meditech is the bane of my existence and I waste at least several minutes on it on every single shift.

 

[RoyBasch]

I've heard multiple malpractice and reimbursement experts agree w/ this style of frequent timestamps and it seems like a relatively bulletproof style. But I don't have a scribe and due to the slowness of charting w/ Meditech and need to multitask, most of my charting is done after my shift when I'm not gonna remember all the times that all the things happened within 2h or so. Immediately editing MDM after a timestamp-able thing happened seems both unrealistic and super-annoying.

So, how do you chart in this style on the ground? Do you write down times for important things as they happen? Do you use timestamps for reassessment and time you viewed results on every single chart regardless of complexity?

Somewhat relatedly: from a billing perspective, how important is it that my documented discharge/admit times are (1) accurate and (2) consistent w/ times written by other providers? Trying to remember and awkwardly click-in these times in Meditech is the bane of my existence and I waste at least several minutes on it on every single shift.

I do try to use time stamps, especially if the issue is time dependent (surgical emergency, trauma, stroke, ACS, etc.) including the time consultants were paged, when they called back, and when they saw the patient or moved them to the OR/cath lab.

If the given problem is not particularly time-sensitive, eg. cholecystitis, I am less disciplined and don't always put a time stamp with the reassessment if I don't know it.

When I am getting behind and cant work on notes in real time (frequently) I write down the time on a small short-hand sheet of key info I keep with all my patient of the shift so that I can put the accurate times in my EMR note later.

 

[Angry Birds]

MDM: 67 yr old m w h/o COPD, DM, and CAD who comes to us w SOB and wheezing x 3 days. vital signs are wnl aside from mild hypoxemia. physical exam reveals moderate wheezing diffusely. impression is of COPD exac: treated w steroids and breathing rx's. pt significantly improved. EKG shows no obvious acute ischemia. labs reviewed and emergently non-actionable. cxray neg but levaquin given. pt hospitalized for further management. IMPRESSION: COPD exacerbation

(I basically write a simple note/summary that another person could actually read and thereby make use of.)

 

[Backpack234]

I think this is an interesting debate and believe there's a spectrum here between MDM to help your colleagues to know what you did vs MDM To help protect yourself in a lawsuit. I remember rotating at a program where the MDM would spell out the entire case. For example

"Ms J is a 25 year old female who came with abd pain. Differential included pregnancy, torsion, cyst, appendicitis, constipation, dysmenorrhea. Pregnancy test was ordered which was negative. Ultrasound revealed large cyst without torsion. Labs included elevated wbc with leftward shift. Concern for appendicitis was noted and U/S of the RLQ revealed a category 3 study. Radiology recommended a CT abd/pelvis which showed appendicitis. Dr. X of surgery was called who requested initiation of unasyn and admission to the surgical service."

At that program, a surgery rotator I was with mentioned that the MDM in these charts was by far the best MDM he had seen since it actually detailed the thought process of the ED physician. I actually brought this up in my residency and was told not to do this. Specifically that listing my exact actions would remove all flexibility that I have in a lawsuit and make it very easy for the prosecutor to show where I got wrong, or what I didn't think of. Instead, they recommended that I let my orders speak for themselves. Now I will always pull my orders, labs, and imaging results into the chart which showed that I did review them. My MDM is typically left blank and I utilize the reassessment section for the data that would go there. It will typically say

"Diagnostic findings as above. These have been discussed with the patient. Symptoms are most likely due to appendicits. Surgery Dr. X consulted who recommends abx and admission. Ordered as above. Pt verbalizes agreement and understanding with this plan. TOC at this time to Dr. X"

You can scroll up in my note and see that I ordered a UCG, UA, CBC, BMP, U/S, CT, etc. You can see that I asked the patient about sexual history, etc. in the HPI. You can see that I performed a pelvic exam and documented no bleeding and an abdominal exam with positive mcburney point tenderness. Those things all speak for themselves. Now, instead of a lawyer saying "you didn't include ectopic pregnancy in your differential! Bad doctor!" I can just point to the pregnancy test that was ordered instead of having to list a complete differential. I could be wrong, but this is how I was taught to do it.

In addition to this, I do make sure to include multiple reassessments to document what's going on. For example "BP unimproved after 2L fluid. Levophed initiated. Will reassess" or "pt with decreased but continued chest pain. Plan for 2 set, dispo"

 

[southerndoc]

Regarding time stamps, there are two ways:

I frequently keep my trackboard view in Epic on the "workup" tab. You can quickly jot notes there. If it's busy and I don't have time to write something, I'll "time mark it" by clicking a lab and just leaving it. I'll later go back and add through the edit icon on the note itself. So, for a hemoglobin of 9, I might click the 9 in the hemoglobin which automatically time stamps it. I'll go back later when finishing notes in the last 2 hours of my shift (while awaiting other studies to come back on patients picked up at end of shift) and add details like "last hemoglobin 9.5".

When I discharge someone or admit, I note my final decision. I have several hard stops (*** in Epic). The first one is in the HPI where I dictate with Dragon, the second is in the MDM portion, third midway in MDM, and fourth is at the end where I put a macro phrase for discharge/admitting that summarizes the diagnosis, things done in ER, discharge prescriptions, etc. In the third ***, I will type ".now:" and it will automatically add the time. I'll then type "***" and hit F2 to go to the next. I can then type my dotphrase for various admission/discharge phrases. I later go back and add the details after the time.

I sometimes will dictate in real time if it's not too busy. I use Dragon Medical Practice Edition. I can say "macro now" and it will use a command to insert the current time. I can then dictate the final decision making.

I've created a ton of commands in Dragon. Macro admit hospitalist, macro admit cardiology, macro discharge, macro AMA, etc. will pull up templates with diagnosis, meds given, meds prescribed, etc. I have differentials in macros too: macro appendicitis, macro diverticulitis, etc. It really speeds things up a lot.

 

[hundreddaysoff]

Regarding time stamps, there are two ways:

I frequently keep my trackboard view in Epic on the "workup" tab. You can quickly jot notes there. If it's busy and I don't have time to write something, I'll "time mark it" by clicking a lab and just leaving it. I'll later go back and add through the edit icon on the note itself. So, for a hemoglobin of 9, I might click the 9 in the hemoglobin which automatically time stamps it. I'll go back later when finishing notes in the last 2 hours of my shift (while awaiting other studies to come back on patients picked up at end of shift) and add details like "last hemoglobin 9.5".

When I discharge someone or admit, I note my final decision. I have several hard stops (*** in Epic). The first one is in the HPI where I dictate with Dragon, the second is in the MDM portion, third midway in MDM, and fourth is at the end where I put a macro phrase for discharge/admitting that summarizes the diagnosis, things done in ER, discharge prescriptions, etc. In the third ***, I will type ".now:" and it will automatically add the time. I'll then type "***" and hit F2 to go to the next. I can then type my dotphrase for various admission/discharge phrases. I later go back and add the details after the time.

I sometimes will dictate in real time if it's not too busy. I use Dragon Medical Practice Edition. I can say "macro now" and it will use a command to insert the current time. I can then dictate the final decision making.

I've created a ton of commands in Dragon. Macro admit hospitalist, macro admit cardiology, macro discharge, macro AMA, etc. will pull up templates with diagnosis, meds given, meds prescribed, etc. I have differentials in macros too: macro appendicitis, macro diverticulitis, etc. It really speeds things up a lot.

Ah, so it's all Epic-specific tricks. Love me some Epic. Unfortunately TH/HCA can no longer even afford scribes at my shop, or an upgrade to a version of Meditech written in the 90s, let alone Epic. So guess that leaves just writing down these important times by hand to chart in this style.

Really like your idea of multiple versions of MDM macros as well for different outcomes in common high-risk problems. Eg, abdominal pain w/o vs w/ CT. The problem I run into is when the outcomes multiply themselves (eg, decision tree becomes admit w/ CT vs admit w/o CT vs d/c w/ CT vs d/c w/o CT).

 

[MechEDoc]

Ah, so it's all Epic-specific tricks. Love me some Epic. Unfortunately TH/HCA can no longer even afford scribes at my shop, or an upgrade to a version of Meditech written in the 90s, let alone Epic. So guess that leaves just writing down these important times by hand to chart in this style.

Really like your idea of multiple versions of MDM macros as well for different outcomes in common high-risk problems. Eg, abdominal pain w/o vs w/ CT. The problem I run into is when the outcomes multiply themselves (eg, decision tree becomes admit w/ CT vs admit w/o CT vs d/c w/ CT vs d/c w/o CT).

Chart in free text. Program a Dragon key (or M Modal) to insert a time stamp.

e.g. 1425 - paged neurosurgery, mannitol started, pupils unequal.

 

[hundreddaysoff]

Chart in free text. Program a Dragon key (or M Modal) to insert a time stamp.

e.g. 1425 - paged neurosurgery, mannitol started, pupils unequal.

Unfortunately, MModal 9.1 appears to lack a timestamp command. Guess it's time to brush up on my Javascript...

 

[Groove]

Seems like a lot of you guys use dragon. I'm starting to think I'm missing out. We have dragon but I typically type everything. I'm admittedly not an expert in dragon but it seems like every time I've tried to use it in the past, I really didn't feel like it saved me much time in the long run that couldn't be accomplished through smart phrases and macros within whatever EMR I was using. (Cerner in my case.)

 

[southerndoc]

Groove, after you train recognition to your speech patterns, you can fly through your dictations. I probably dictate at 200 wpm and get about 99% accuracy. This goes down at the end of a night shift when I start slurring my words from being tired, but it's still >95%.

For me, dictating is a lot easier than typing. It's easier to tell a story than it is to type one. It flows more easily.

You just have to make sure you read over what you dictate. Nothing like a patient "prepped and raped in the usual sterile fashion," or "history of eating hemorrhoids" instead of bleeding hemorrhoids, "uterine embolism" instead of pulmonary embolism, and of course the best I've ever seen: instead of Pickwickian syndrome it transcribed "tickle dick syndrome."

 

[gro2001]

It also matters what note format you use. Dragon is most time saving when you are using a completely free text note. If you prefer a note which has some separate boxes for different things or is pre-populated with some data, then you will spend too much time clicking around to make sure you are dictating in the right place in the note.

 

[gutonc]

You just have to make sure you read over what you dictate. Nothing like a patient "prepped and raped in the usual sterile fashion," or "history of eating hemorrhoids" instead of bleeding hemorrhoids, "uterine embolism" instead of pulmonary embolism, and of course the best I've ever seen: instead of Pickwickian syndrome it transcribed "tickle dick syndrome."

"Recent TTE shows global warming ocean maladies"
"Admit to the hospital to determine the cause of his persistent porn eating"

Both on the same patient from the same attending that I wound up admitting to the BMT service in the middle of night while moonlighting. The actual admission ruined my night. The note made it funny at least.

 

[gutonc]

Seems like a lot of you guys use dragon. I'm starting to think I'm missing out. We have dragon but I typically type everything. I'm admittedly not an expert in dragon but it seems like every time I've tried to use it in the past, I really didn't feel like it saved me much time in the long run that couldn't be accomplished through smart phrases and macros within whatever EMR I was using. (Cerner in my case.)

I'm with Groove on this one. I can absolutely see how Dragon can be really useful. But, before my hospital invested in it, I'd already spent a few years tightening up my templates/macros/smartphrases/etc in Epic, to the point that, when I did wind up having to use it for 6 months a couple of years ago (broken arm), it slowed me down considerably. I obviously got better with it over time, but as soon as I was able to type again, I dropped Dragon and my productivity skyrocketed.

YMMV of course.

 

[MechEDoc]

I find that Dragon massively increases my productivity. However, I have been using it for 5 years, I have developed a set of templates that work very well with Dragon, and a program numerous shortcuts.

 

[Groove]

Does anyone use Cerner FirstNet and if so, do you put your MDM blurb in the "Notes" section at the bottom of the MDM or the "Rationale" right under differential ddx? I've always been confused on where to type all my stuff. I usually put it in "notes" because it's always made sense to me if someone is reading the chart, they would want to see my MDM AFTER seeing the lab and imaging results, etc.. However some of my colleagues put everything in "Rationale" which I've always thought was rationale for the DDx. So confusing, lol. All of us are basically in 2 camps, those of us who document in "Notes" and those that document in "Rationale".

The MDM template basically splits MDM into the following:
DDX
Rationale
Documents Reviewed
Orders
Cardiac Monitor
EKG
Lab Results
Imaging Results
Notes

 

[hypnix]

I use a word document with meditech and have the room numbers saved. I dictate my mdm into the Word document and put time stamps, reeval, etc. I have a scribe who I have do the hpi and physical exam. However, depending on the scribe, I have them entire time stamps with phone calls and reevaluations. I also work some other jobs and don't have scribes so sometimes I don't utilize my scribes as well.

I also found if you open more than one tracker in Meditech, you can open up more than one patient chart. I usually only do this for when I don’t want to click out of a current chart (saving a chart takes like 10 clicks and one minute of loading) but have to speak to another doc about a patient.

 

[MechEDoc]

I use a word document with meditech and have the room numbers saved. I dictate my mdm into the Word document and put time stamps, reeval, etc. I have a scribe who I have do the hpi and physical exam. However, depending on the scribe, I have them entire time stamps with phone calls and reevaluations. I also work some other jobs and don't have scribes so sometimes I don't utilize my scribes as well.

I also found if you open more than one tracker in Meditech, you can open up more than one patient chart. I usually only do this for when I don’t want to click out of a current chart (saving a chart takes like 10 clicks and one minute of loading) but have to speak to another doc about a patient.

I've done something very similar when using scribes and Meditech. I have a paid account with the BAA (business associate agreement) for HIPAA compliance with Microsoft one drive. That allows for concurrent editing of MS Word documents. The scribe can login on their laptop using one drive online, concurrently edit in a Word document (one per patient), update the document as we go through the chart, and we are never fighting to access the EMR simultaneously. The entire document is then pasted into Meditech as a SOAP note.

E.g.
HPI
[]

M/S/F/SocHx notable for: [please see HPI]; remainder reviewed with patient and in chart.

ROS: Negative constitutional, eye, cardiovascular, pulmonary, GI, GU, MSK, skin, neurologic, psychiatric, endocrine unless noted in the HPI.

Exam
Gen: [Pleasant, non-toxic appearing, resting comfortably.]
HEENT: [NC, AT, PEERL, EOMI.]
Resp: [Clear to auscultation bilaterally, normal work of breathing, no accessory muscle usage.]
Card: [Regular rate and rhythm with no murmurs, rubs, or gallops, extremities warm and well perfused.]
GI: [Non-tender to palpation throughout all quadrants, no focal tenderness at McBurney's point, negative Murphy's sign, non-distended, no rebound or guarding.]
GU: [No suprapubic tenderness to palpation.]
MSK: [No visible deformities, strength and tone without visually appreciable deficit.]
Skin: [Normal color with no visible lesions.]
Neuro: [AO x 3, no facial asymmetry, vision and hearing WNL.]
Psych: [Mood and affect appropriate.]

Labs / Imaging:
WBC [], Hb [], Na [], K [], total bilirubin [], AST [], ALT [], ALP [], lipase [].
troponin [].
CXR: [No acute cardiopulmonary disease process]. [No focal infiltrate, cardiomegaly, rib fractures, or mediastinal widening, lung markings extend to the periphery bilaterally and there are no deep sulci.] Radiologist's read pending.
EKG: SR at [] BPM with no ST-segment elevations or depressions, T-wave inversions or new LBBB.
[]
MDM
Previous chart, nursing note, labs, imaging, and vitals reviewed.
A: []

DDx: []

Evaluation: []

ED Course: []

Disposition: []

Impression: []

 

[southerndoc]

How do you get access to HIPAA compliance/BAA with OneDrive?

 

[MechEDoc]

It's built into their standard contract. Security outside of the OneDrive environment is up to you - i.e. turn on Windows 10 whole disk encryption, etc.

 

[NITRAS]

It also matters what note format you use. Dragon is most time saving when you are using a completely free text note. If you prefer a note which has some separate boxes for different things or is pre-populated with some data, then you will spend too much time clicking around to make sure you are dictating in the right place in the note.

I dictate into a word document or dictation box, then copy past.

I like Dragon, but I really miss true dictation. I did it in residency. I know it is a thing of the past, but it was great while it lasted. The ability to see a patient, write a brief note, then dictate a complete H&P in a couple minutes. . . . . oh the days.

I once dictated "Va**** breath" with Dragon. I have no idea how that happened.

 

[southerndoc]

It's built into their standard contract. Security outside of the OneDrive environment is up to you - i.e. turn on Windows 10 whole disk encryption, etc.

I have Bitlocker turned on for drive encryption. I thought you were suggesting there was a special option to turn on to enable HIPAA-compliant encryption. (My phone service for my office phone -- RingCentral -- has an option for HIPAA compliance that encrypts faxes/calls, automatically deletes faxes/voicemails/texts after 30 days, etc.).

 

[turkeyjerky]

Does anyone use Cerner FirstNet and if so, do you put your MDM blurb in the "Notes" section at the bottom of the MDM or the "Rationale" right under differential ddx? I've always been confused on where to type all my stuff. I usually put it in "notes" because it's always made sense to me if someone is reading the chart, they would want to see my MDM AFTER seeing the lab and imaging results, etc.. However some of my colleagues put everything in "Rationale" which I've always thought was rationale for the DDx. So confusing, lol. All of us are basically in 2 camps, those of us who document in "Notes" and those that document in "Rationale".

The MDM template basically splits MDM into the following:
DDX
Rationale
Documents Reviewed
Orders
Cardiac Monitor
EKG
Lab Results
Imaging Results
Notes

I don't really think it matters, and don't pay attention to it. Sometimes, if I click on the differential button my accident, I just put it all there.

I do wish that they just had a section labeled MDM, but this isn't a homework assignment from a persnickety grade school teacher--as long as you communicate the information I think it's fine.

 

[hundreddaysoff]

I dictate into a word document or dictation box, then copy past.

I like Dragon, but I really miss true dictation. I did it in residency. I know it is a thing of the past, but it was great while it lasted. The ability to see a patient, write a brief note, then dictate a complete H&P in a couple minutes. . . . . oh the days.

I once dictated "Va**** breath" with Dragon. I have no idea how that happened.

Can't disagree. The thing that gets me about Meditech is that it's *almost* possible to use Dragon or MModal or whatever to "dictate" the entire note into Word and then copy/paste individual sections into Meditech. BUT... then Meditech also has like 4 or 5 clicky boxes that are mandatory, redundant, and useless. Finding and clicking the mandatory boxes (for which I always click the exact same things anyway) slows me down by a couple minutes for each note.

 

[MechEDoc]

To answer the original question about what is in my MDM.

1. Dx
2. Management
3. Verbal diarrhea and defensive prose.

 

[Dr.CCM]

I use a word document with meditech and have the room numbers saved. I dictate my mdm into the Word document and put time stamps, reeval, etc. I have a scribe who I have do the hpi and physical exam. However, depending on the scribe, I have them entire time stamps with phone calls and reevaluations. I also work some other jobs and don't have scribes so sometimes I don't utilize my scribes as well.

I also found if you open more than one tracker in Meditech, you can open up more than one patient chart. I usually only do this for when I don’t want to click out of a current chart (saving a chart takes like 10 clicks and one minute of loading) but have to speak to another doc about a patient.

Why not just type in/dictate the Mdm in the section as you go. I hate meditech (HCA) by the way. It adds much more stress to your job when you compare epic and Cerner to it. Hell CPRS is even better than that POS.

 

[hypnix]

Why not just type in/dictate the Mdm in the section as you go. I hate meditech (HCA) by the way. It adds much more stress to your job when you compare epic and Cerner to it. Hell CPRS is even better than that POS.

I do that at times as well. Sometimes it's just easier to see a few patients and crank out the MDMs while the scribe finishes the chart. It takes like probably 10 clicks to open a chart to get the MDM section in Meditech so it would be inefficient to timestamp evals and phone calls each time in a given patient chart. In short, Meditech blows and needs to go away. Although, I work at a site with Cerner and multiple patient chart functionality was removed.

 

[thegenius]

Does anyone use Cerner FirstNet and if so, do you put your MDM blurb in the "Notes" section at the bottom of the MDM or the "Rationale" right under differential ddx? I've always been confused on where to type all my stuff. I usually put it in "notes" because it's always made sense to me if someone is reading the chart, they would want to see my MDM AFTER seeing the lab and imaging results, etc.. However some of my colleagues put everything in "Rationale" which I've always thought was rationale for the DDx. So confusing, lol. All of us are basically in 2 camps, those of us who document in "Notes" and those that document in "Rationale".

The MDM template basically splits MDM into the following:
DDX
Rationale
Documents Reviewed
Orders
Cardiac Monitor
EKG
Lab Results
Imaging Results
Notes

I user Cerner FirstNet.

I think MDM should be read after you get a history and physical, and before you order tests. That's my theory on it.

I put it in the Rationale section. I leave the Notes alone. Then I use 1, or more, of the re-eval sections for my reevaluations.

 

[KGflyboy]

Good news: We have much better people running medicare now, with the current administration. They're finally, FINALLY, at least considering reducing the ridiculous amount of red tape that has been heaped on us, for so long, regarding documentation. Medicare may do away with this billing scheme based on MDM. And EM codes may get a boost.

Brace for a big shake-up to E/M coding. CMS announced its intention to pursue “comprehensive reform of E/M documentation guidelines” in the 2018 proposed Medicare physician fee schedule released July 13...“As long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam,” states the agency....Some potentially misvalued codes may get a boost. CMS is wondering whether to review emergency department visits (99281-99385) as undervalued “given the increased acuity of the patient population and the heterogeneity” of ED locations, such as free-standing and off-campus emergency departments.

Part B News | CMS may overhaul E/M coding; history (and exam) may ...

Also, "Includes many provisions aimed at easing provider paperwork burden"

2019 Proposed Medicare Fee Schedule Announced


Promising signs, but very early, and not yet final.

cc: @ERCAT

When will we find out more? I haven't heard anything yet. Did they scrap these ideas?

 

[Birdstrike]

When will we find out more? I haven't heard anything yet. Did they scrap these ideas?

I think the final 2019 medicare rules came out last month, but I haven't heard exactly how it turned out, related to the things I mentioned in the post above. I did hear, that some of the proposed changes got delayed until 2020, but I'm not 100% sure. There's so much in these Medicare updates, it takes times for each speciality to pull out and summarize what's relevant to them.

 

[deleted547339]

For the record I am an ER PA, practicing two and a half years. Trying to get faster and more efficient and one thing I have noted is that my medical decision making sections of my charts are often redundant and possibly overly detailed, stating info again that was relayed in the HPI or PE. It’s an obsessive habit I have; however my charting just feels crappy to me if I don’t do this exact format. Here’s an example of what my typical MDM would look like.

Ms. Smith is a 62 year old female with a history of diabetes who presented to the emergency department today with left lower abdominal pain and nausea for three days. She denies fevers or vomiting. On examination she was well appearing and in no distress with vitals remarkable only for an elevated blood pressure. There was mild left lower quadrant tenderness without guarding or rebound tenderness. Blood work revealed no leukocytosis. Urinalysis indicated 2+ bacteria without elevation in white cells, nitrite or leukocyte esterase. CT of the abdomen and pelvis with intravenous contrast showed acute sigmoid diverticulitis without abscess. Incidentally Ms. Smith had a cyst on the left kidney which I informed her about; she understands she needs to see her primary care doctor for further evaluation. She was given a liter of normal saline with morphine and odansetron, and on re-evaluation symptoms were much improved. Repeat abdominal examination was benign and she was tolerant of oral fluids. At this point I feel discharge is appropriate. I prescribed metronidazole and ciprofloxaxin, and advised close follow up with primary care. I urged her to return to the emergency department if new or worsening symptoms like fevers or intractable pain. She was discharged in stable condition with her husband taking her home.

Redundant right? This would be a shorter MDM for me. If the case is not so slam dunk I might go into more of my differentials and why I felt Ms Smith does not need further testing.

I get compliments regularly for my thorough and detailed and relatively type free charts so I hate to change things up too dramatically. Anyone have suggestions for me on MDM?

That’s a lot of HPI....

My mdm would be:
62yoF PMH DM here w/ LLQ pn, n/v x3d. VSS. Nontoxic. CT, labs, urine - below. Tolerating PO. Appropriate for outpt abx. Understands return precautions. Informed of incidental findings.

That says everything you said but took me 10% of the time.

 

[Angry Birds]

That’s a lot of HPI....

My mdm would be:
62yoF PMH DM here w/ LLQ pn, n/v x3d. VSS. Nontoxic. CT, labs, urine - below. Tolerating PO. Appropriate for outpt abx. Understands return precautions. Informed of incidental findings.

That says everything you said but took me 10% of the time.

I would split the difference between the two... I like TimesNewRoman's approach, but I would want a quick interpretation of the pertinent positives from the labs/imaging, so I'd change it to:

62yoF PMH DM here w/ LLQ pn, n/v x3d. VSS. Nontoxic. CT, labs, urine - reviewed, c/w acute sigmoid diverticulitis w/o perf. Tolerating PO. Exit abdominal exam is benign. Appropriate for outpt abx. Understands return precautions. Informed of incidental findings [list what they are, or actually you can just put it in discharge instructions, which is better.]

I might fatten it out a bit more, but I think in between your two MDM's... Reason is that I think the MDM should stand alone so that another ER doctor can read it when the patient comes back and can know everything he/she needs to know. I think MDM is the only important part of a chart from that standpoint. The rest is for coding and legal reasons.

 

[deleted859535]

Agree with fleshing out a bit. I'm too wordy in MDMs, and it takes a lot of time. I trim where I can, increasingly so, but err towards elaboration. More in cases where you clinically rule things out. Chest pain and headaches being big examples -- briefly alluding to consideration for PEs, dissections, SAHs, meningitis, etc, and why I didn't pursue diagnostic testing for those things. Defensive, but the reality is that if anything ever happens, I want the chart to be able to stand alone and say >90% of anything I'd say in a deposition. Doing this quickly is an art form.