The high overall level of medical decision making requires which of the following?
A. reflects more complicated coordination on the part of the physician performing the E/M service but does not pose an excessive risk to the patient
B. reflects a relatively uncomplicated process of medical decision making
C. reflects a very intricate process of difficult or extreme decisions, difficult coordination of diagnostic tests or results, complex diagnosis or diagnoses, or convoluted management options
D. reflects a more complicated combination of medical decision-making elements but does not warrant a significant or substantial level of medical decision making
Question 2
The physician sees a seven-year-old patient for a first visit. Patient had a wood sliver in his right hand that is now swollen, tender, and red. Also, just before arriving at the clinic, the patient also suffered a bee sting on his left arm that resulted in mild swelling. History reveals the patient has had no history of severe reaction to bee stings. No identified signs of anaphylaxis from the bee sting. Physical examination of the patient's right hand identifies possible infection of sliver wound site; the physician requests the patient's previous medical records from his former clinic to identify the status of the patient's tetanus immunization status. Physician recommends Epsom salt baths twice daily for the infected right hand and issues a prescription for antibiotics in the event the baths do not help improve the infection. What is the overall level of medical decision making?
A. Straightforward
B. Low
C. Moderate
D. High
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Comparison of Paper Medical Records and Electronic Health Records
Medical assistant administering an injection.
Upper-Level Maps