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Evaluation and Management of Medical Decisions
When making medical decisions, three significant key components of evaluation and management services are considered: history, examination, and medical decision-making. History, the selected critical components highlighted, is critical in medical decision-making since treatment heavily relies on the patients records (Buhmann et al., 2018). Specific to chronic health problems, the information contained guides the practitioner in determining the treatment approach to take when handling a patients health problem (Buhmann et al., 2018). The significance of medical records in determining the treatment program to administer to the patient serves as a significant point, notably if past treatment plans have failed.
The E/M service levels are associated with history from the four types of history, and all constitute some or all of the following elements. The chief complaint is a clear statement that describes health conditions, symptoms, or any related information linked to the cause of the problem (Buhmann et al., 2018). History of present illnesses (HPI) highlights a chronic illustration of the problems development from the first to the present sign. A review of systems (ROS) presents a body of the systems inventory gained via a series of identified symptoms, or signs, experienced by the patient (Edalat et al., 2017). Social, family, or history (PFSH) presents a historical review of the problem(s) identified using HPI.
The significant levels associated with history are comprehensive, allowing practitioners to have an entire history of the problem. Detailed, where the available information provides thorough content regarding the complication. Expanded problem-focused, where the practitioner gains alternative approaches previously used in handling the problem (Edalat et al., 2017). Problem-focused allows the decision-maker to understand the specific areas of attention essential in handling the issue. The process involved in determining documentation of medical history adheres to three steps. First, a policy is set to assess the documentation policy to ensure the fundamental points are covered (Edalat et al., 2017). Second, the staff is educated on the essentials, how to save time, and practice documentation skills.
References
Buhmann, A., Likely, F., & Geddes, D. (February 05, 2018). Communication evaluation and measurement: connecting research to practice. Journal of Communication Management, 22, 1, 113-119.
Edalat, F., Lindquester, W. S., Gill, A. E., Simoneaux, S. F., Gaines, J., & Hawkins, C. M. (2017). The effects of expanding outpatient and inpatient evaluation and management services in a pediatric interventional radiology practice. Pediatric Radiology, 47, 3, 321-326.
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