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The following information was documented on a patient seen in the physician’s office. Review of lab...

The following information was documented on a patient seen in the physician’s office. Review of lab tests and uroflowmetry suggests benign prostatic hypertrophy. The patient’s urine flow was 8 mm. PSA test was slightly elevated. Repeat PSA today. TURP was discussed with patient. Risks and benefits of procedure discussed in detail. Patient has agreed to surgery. Surgery will be scheduled for next week. Which level of medical decision making is documented?

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Answer #1

Low complexity medical decision making is documented.

  • 2 established problem that is 8 mm urine flow and elevated PSA test are known to the physician.Total problem point = 2
  • The physician have reviewed the primary data ie,review of lab tests and uroflowmetry and P SA test is been done.Total data point = 1
  • The level of risk in management option is minor surgery with no identified risk factors.So risk is low.
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