MDM structure, in plain English
Medical decision-making is the part of the note your AI scribe can’t write, because you think it instead of saying it. Three things drive it: how many problems you handled, what data you reviewed, and how much risk the visit carried.
Problems
What you were managing, including the dangerous diagnoses you considered and dropped.
Data
What you reviewed — labs, imaging, old records, the ECG, the consultant call.
Risk
The risk of the presentation, the workup, and the disposition you chose.
01Show the reasoning, not just the result
“Labs reviewed” gets you nothing. The value is what the result meant for this patient.
02Name the can’t-miss diagnoses
Don’t just write the diagnosis you landed on. Write the dangerous ones you ruled out, and why. “Considered it, here’s why it isn’t” is the most defensible line you can put in a chart.
03Make risk a sentence
Use a named, cited tool when one fits, and say the residual risk out loud. More on that in Guide 02.
Put it together
The Workup walks this structure and gives you a block to paste alongside your scribe’s note.
Educational only. Synthetic examples. Not medical advice.