Which term describes Medical Decision Making, the process of determining the diagnosis and management options for a patient?

• A. Discharge instructions
• B. MDM
• C. History and Physical
• D. Tests ordered by the physician to aid in establishing a diagnosis

Answer: (B)

Medical Decision Making is the clinician’s reasoning process used to determine the diagnosis and the management plan for a patient. It involves weighing the history, physical findings, and data from tests to form a differential, decide which data are needed, interpret results, assess risk, and choose the appropriate treatment or disposition. The other items are related to different parts of the visit: discharge instructions are post-visit guidance, the History and Physical documents the initial examination, and tests ordered are tools used within the decision-making process rather than the process itself.