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Encounter Data

Date of Service Patient Type Established New

Medical Decision Making

Number and Complexity of Problems 1 self-limited or minor problem 2 or more self-limited or minor problems 1 stable, chronic illness 1 acute, uncomplicated illness or injury 2 or more stable, chronic illnesses 1 chronic illness with exacerbation 1 acute illness with systemic symptoms 1 undiagnosed new problem with uncertain prognosis 1 chronic illness with severe exacerbation 1 acute or chronic illness that poses a threat to life

Data Reviewed and Analyzed

External Notes Reviewed Unique Tests Reviewed Unique Tests Ordered Independent Historian Independent Test Interpretation Discussion with External Physician

Total Data Points: 0

Risk of Complications Minimal (e.g., rest, gargles) Low (e.g., OTC drugs, minor surgery) Moderate (e.g., prescription drugs) High (e.g., major surgery with risk)

Results

MDM Level: Not Calculated

E/M Code: Not Calculated