blaymon
Networker
The guidelines state:
"Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging
that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented."
Elsewhere in the guidelines it states:
"The risk of complications and/or morbidity or mortality of patient management decisions made at the
visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes
the possible management options selected and those considered but not selected, after shared MDM
with the patient and/or family. For example, a decision about hospitalization includes consideration of
alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of
support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia
with an acute condition that would generally warrant inpatient care, but for whom the goal is
palliative treatment."
If I order a urinalysis, urine pregnancy test and a urine culture but the patient refuses and I document it appropriately, would that count as 3 points towards the complexity of data column or would it count towards the risk of morbidity/mortality column?
"Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging
that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented."
Elsewhere in the guidelines it states:
"The risk of complications and/or morbidity or mortality of patient management decisions made at the
visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes
the possible management options selected and those considered but not selected, after shared MDM
with the patient and/or family. For example, a decision about hospitalization includes consideration of
alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of
support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia
with an acute condition that would generally warrant inpatient care, but for whom the goal is
palliative treatment."
If I order a urinalysis, urine pregnancy test and a urine culture but the patient refuses and I document it appropriately, would that count as 3 points towards the complexity of data column or would it count towards the risk of morbidity/mortality column?