It could be said that the overall medical decision making is the MOST difficult element to identify. Do you agree with this statement? In at least 10 sentences, explain why you do agree with this statement or why you do not agree with this statement
What will be an ideal response?
· Answer should include:
· The history is the documentation of what is said by the patient, while the physical examination is determined by the anatomy of the human body and the patient's physiology and/or pathology.
· However, the medical decision making is the one element of the performed E/M service visit that occurs primarily within the mind of the performing physician and is documented in the ordered diagnostic options, any diagnostic findings or results, and the documented management option identified by the physician.
· In order to identify objectively a specific level for the overall level of medical decision making, it is important to assign certain "levels" of complexity. This can be daunting since physicians have such advanced education and experience. As a result, the reader should have a certain amount of clinical knowledge or, at least, a willingness to research and learn, as well as think logically about the documented medical decision making in the context of the performed E/M service. If the reader does not understand the documented diagnostic test result, then some research may be needed in order to understand how this medical decision making is most appropriate for the presenting problem.
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