Here are just a few helpful tips for properly documenting MDM

• • List your impressions and differential diagnoses
  • Document review of current meds and medication reconciliation
  • Document medical care provided prior to patient’s arrival (e.g. EMS)
  • Note information obtained from sources other than the patient (parent, guardian, relative, caregiver, nursing home)

• List all interventions and procedures, medications including route of administration, re-assessments, response to treatment, changes in status that may outweigh the presenting problem
• Document pertinent details of discussions with PCP and/or consultants
• Note pertinent contents of any old records reviewed
• Document impression of ancillary test results
• Record “per my review for EKG or imaging studies not formally interpreted
• Record discharge instructions including medications, and follow-up
• Give a definitive time frame for a phone or office follow-up
• Document the diagnosis(es) and list all that are pertinent
• Remember to note acute or emergent when applicable
• Review Nurses Notes for accuracy in supporting orders, interventions, disposition