Documentation

As you implement an MDM model, it is necessary to include the documentation to support your decision. This includes any test ordered for every step of assessment and treatment, outside records request, provider-to-provider discussions, and patient to provider discussions, independent historians, and remember to document using language provided by the AMA, such as stable, chronic, acute, uncomplicated, progression, new problem, uncertain prognosis, discussion of management, or test interpretation, independent historian, just to name a few. You can refer to these words in the AMA grid we’ll have provided for you. 

All good points Maritza. Certainly documentation has always been critical, but with the labeling of the medical decision making process as being more simple and straightforward than in the past, it’s more important than ever to use the correct vernacular and document, document, document. So that one, you cover yourself from the medical malpractice side, but also and maybe more important as far as practice management goes, from the audit side. So, thank you Maritza.