Question

dr. Smith saw Maria Santos for a subsequent hospital visit. Ms. Santos is post tonsillectomy times two days. Patient is still unable to speak in a clear voice. Bleeding has increased in the surgical area. Patient will have to be taken back to the operating room for hemorrhage control. Which level of MDM is documented?

Answer 1

MDM is medical decision making . There are four levels of MDM of incrementally increasing complexity:

Straightforward

Low Complexity

Moderate Complexity

High Complexity

# Physicians must stratify the MDM into one of the above levels of complexity based on:

The nature and number of clinical problems

The amount and complexity of the data reviewed by the physician

The risk of morbidity and mortality to the patient.

# The level of MDM documented in this case is straightforward because the number of diagnosis or management option is minimal , amount or complexity of data to be reviewed is minimal and risk of complications or morbidity or mortality is minimal .