One self-limited or minor problem, e.g., cold, insect bite, tinea corporis
Laboratory tests
Chest X-rays
EKG/EEG
Urinalysis
Ultrasound/Echocardiogram
KOH prep
Rest
Gargles
Elastic bandages
Superficial dressings
Low
Two or more self-limited or minor problems
One stable chronic illness, e.g., well controlled HTN, DM2, cataract
Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
Physiologic tests not under stress, e.g., PFTs
Non-cardiovascular imaging studies with contrast, e.g., barium enema
Superficial needle biopsy
Over the counter drugs
Minor surgery, with no identified risk factors
Physical therapy
Occupational therapy
IV fluids, without additives
Moderate
One or more chronic illness with mild exacerbation or progression
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
Acute illness with systemic symptoms (e.g., pyelonephritis, colitis)
Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
Diagnostic endoscopies, with no identified risk
Deep needle, or incisional biopsies
Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization
Obtain fluid from body cavity, e.g., LP/thoracentesis
Minor surgery, with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic), with no identified risk
Prescription drug management
Therapeutic nuclear medicine
IV fluids, with additives
Closed treatment of fracture or dislocation, without manipulation
High
One or more chronic illness, with severe exacerbation or progression
Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g.,
multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness, with
potential threat to self or others, peritonitis, ARF
An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss
Cardiovascular imaging, with contrast, with identified risk factors
Cardiac EP studies
Diagnostic endoscopies, with identified risk factors
Discography
Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
Emergency major surgery (open, percutaneous, endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate, or to de-escalate care because of poor prognosis
RESET PAGE
RESTART
PREVIOUSNEXT
RESULTS
OVERALL MDM
PROBLEM POINTS
DATA POINTS
RISK
Straightforward
≤1
≤1
Minimal
Low
2
2
Low
Moderate
3
3
Moderate
High
≥4
≥4
High
Two out of three dimensions required for any given level of complexity.
