Overall complexity of decision making: high complexity Subsequent hospital visit for a 55 year old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acute respiratory distress requiring ventilatory support in the ICU but was stabilized, extubated, and transferred to the floor. Now has developed acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention and hypoxemia. Lab, CXR, done; discussed with pulmonary medicine; ordered ABG’s medications. # diagnoses or treatment options extensive (established problems, worsening + new problems) – complexity of data - extensive (lab, radiology, discussion w/other provider) risk of complication high (chronic illness with severe exacerbation, acute illness that may pose a threat – to life/bodily function) Overall complexity of decision making: high complexity Office consultation for 58 year old man with a history of MI and CHF who complains of the recent onset of rest angina and shortness or breath. The patient has a systolic blood pressure of 90 mmHg and is in Class IV heart failure. Lab, CXR, EKG and echo done; records reviewed. Meds prescribed. # diagnoses or treatment options extensive (new problems, planned) – add’l w/u complexity of data - extensive (lab, radiology, EKG/echo, review of records) risk of complication high (chronic illness with severe exacerbation) – Overall complexity of decision making: high complexity Initial inpatient consultation for 76 year old female with massive, life-threatening gastrointestinal hemorrhage and chest pain. Lab, diagnostic imaging, EKG performed, blood transfusion given, discussed with surgeon. # diagnoses or treatment options extensive (new problems, planned) – add’l w/u complexity of data - extensive (lab, radiology, EKG, discuss with other provider) risk of complication high (acute illness that may pose a threat to life/bodily function) – Overall complexity of decision making: high complexity
Overall complexity of decision making: high complexity Subsequent hospital visit for a 55 year old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acute respiratory distress requiring ventilatory support in the ICU but was stabilized, extubated, and transferred to the floor. Now has developed acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention and hypoxemia. Lab, CXR, ABG’s done; discussed with pulmonary medicine; ordered medications. # diagnoses or treatment options – extensive (established problems, worsening + new problems) complexity of data - extensive (lab, radiology, discussion w/other provider) risk of complication – high (chronic illness with severe exacerbation, acute illness that may pose a threat to life/bodily function) Overall complexity of decision making: high complexity Office consultation for 58 year old man with a history of MI and CHF who complains of the recent onset of rest angina and shortness or breath. The patient has a systolic blood pressure of 90 mmHg and is in Class IV heart failure. Lab, CXR, EKG and echo done; records reviewed. Meds prescribed. # diagnoses or treatment options – extensive (new problems, add’l w/u planned) complexity of data - extensive (lab, radiology, EKG/echo, review of records) risk of complication – high (chronic illness with severe exacerbation) Overall complexity of decision making: high complexity Initial inpatient consultation for 76 year old female with massive, life-threatening gastrointestinal hemorrhage and chest pain. Lab, diagnostic imaging, EKG performed, blood transfusion given, discussed with surgeon. # diagnoses or treatment options – extensive (new problems, add’l w/u planned) complexity of data - extensive (lab, radiology, EKG, discuss with other provider) risk of complication – high (acute illness that may pose a threat to life/bodily function) Overall complexity of decision making: high complexity
Examples-of-MDM-levels.docx