The physician documents a limited number of diagnoses and/or management options, a limited amount and/or complexity of data to be reviewed, and a moderate risk of complications, comorbidities and/or mortality. What is the overall level of medical decision making?
A. Straightforward
B. Low
C. Moderate
D. High
Question 2
The overall level of medical decision making is determined by the lowest of the three elements number of diagnosis(es) and/or management options, amount and/or complexity of data to be reviewed, and risk of complications, comorbidity, or mortality.
Read the following medical decision making documentation, then answer the following questions.
Impression: 29-year-old woman well known to this physician returns to the clinic with possible extraesophageal manifestation of GERD.
Plan: Chest X-ray ordered to rule out lung congestion or esophageal mass. Upon independent review of X-ray, consider prescription for proton pump inhibitor therapy and change of lifestyle to reduce stress and improve digestion, including eating five small meals throughout day and no food or drink more than 3 hours before bedtime.
Follow up in one week.
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