MEDICAL DECISION MAKING:

Dx: Types of problem:

_____Self-limited or minor
_____Established same/improving ____ Established, worsening
_____New, no additional workup ____New, with additional workup

_____Are any of the above illnesses a severe exacerbation, progression or side effect of treatment?

Management Options:

_____OTC Meds ____Phys/Occ Therapy
_____Prescrip/IM meds ____Closed Fx/dislocation w/o
_____IV meds manipulation
_____IV meds w/ additives ____Minor surg w/o risk factors
_____High Risk meds ____Minor surg w/ risk factors
_____Telemetry ____Major surg w/o risk factors
_____Respiratory treatments ____Major surg w/ risk factors
_____Nuclear Medicine ____Major emergency surger
____Decision not to resuscitate
----------------------------
_____Decision to obtain old medical records and/or obtain Hx from someone other than patient
_____Review and summ of old records and/or obtain Hx
from someone other than patient
_____Discussion of case with another health care provider

Time spent in minutes w/ patient or family_____________

Labs:

_____CBC/UA ____Cardiac enzymes
_____Flu/Strep/Monospot ____ABG
_____PG test _____PT/PTT
_____Amylase _____T&C
_____BUN/Creat _____Superficial Bx
_____Electrolytes _____Deep/incisional Bx
_____ETOH/Drug screen ____Other labs 0-9
_____Chem profile
----------------------
_____Independent visualization of test
_____Discussion w/ performing\ physician

X-ray/Radiology

_____Chest ____GI/Gallbladder series
_____Extremities ____IVP
_____Abdomen ____CAT scan
_____Hip/Pelvis ____MRI
_____C-spine ____Vascular studies w/o risk
_____Diagnostic US ____Vascular studies w/ risk
_____Discography ____Other X-ray 0-9
_____T/L spine
--------------------------
_____Independent visualization of test
_____Discussion w/ performing physician

Other diagnostic tests:

_____EKG ____Nuclear scan
_____Holter ____Lumbar puncture
_____Treadmill/stress ____Thoracentesis
_____EEG/EMG ____Culdocentesis
_____Vectorcardiogram ____Endoscope w/o risk
_____Doppler flow ____Endoscope w/ risk
_____Pulmonary
---------------------
_____Independent visualization of test
_____Discussion w/ performing physician