The moderate overall level of medical decision making requires which of the following?
A. 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
B. 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
C. Reflects a more complicated combination of medical decision-making elements but does not warrant a significant or substantial level of medical decision making
D. Reflects a relatively uncomplicated process of medical decision making
Question 2
The patient presents to a new clinic for a first visit to be seen for a respiratory complaint. The physician orders a chest X-ray and independently reviews the radiology film and, diagnosis the patient with bronchitis and prescribes antibiotics. What is the overall level of medical decision making?
A. Straightforward
B. Low
C. Moderate
D. High
An example of a late entry to the medical record.
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