That is a good question. The audit tool is a "tool" and I use it daily. You have to consider the results of the tests ordered, and if any stabilizing medications had to be given and how they were administered. Were any pain medications given, perscriptions at discharge? Also, sometimes if everything fits a certain level according to the tool guide, but just needs a push to go from say, a 4 to a 5, go back to your presenting symptom and decide if it was severe enough to fall under "high" severity. Also, make sure the MDM points were given appropriately.
If everything was normal, and no additional treatment was needed, that sounds like a moderate level, albiet a very strong level 4. I would want to give the physician a level 5 too, but having just taken the CEDC exam I found that the guidelines are more strict than I thought.
Bottom line, whatever level you chose, be sure you have valid reasons for selecting it and can back it up with documentation.
I hope this helps!
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