We are excited to announce the availability of two new features in DAX Copilot for DMO users - customizable templates and a medical decision making note style for the emergency department.

 

Customizable Templates

Users can now enhance their documentation efficiency with customizable templates (included in the style wizard). Clinical findings from the patient conversation will be automatically merged into the template.

Users can choose to have their customized template applied all the time (as the default) or for each individual encounter. The customizable templates are available in these note sections: Allergies, Physical Exam, Assessment & Plan

 

Emergency Department Medical Decision Making (ED MDM) Note Style

This feature provides a structured documentation approach to capturing the clinicians thought process and patient care journey in the emergency department. Clinician’s must state the content, ensuring that each section accurately reflects the patient’s care and management. Every segment is crucial for a comprehensive record of the patient’s ED experience.

 

The sections available in the ED MDM note are:

• Initial Assessment

• ED Course

• Final Assessment

• Diagnoses

• Disposition

• Follow-up Instructions

• Critical Care Time

• MDM Components Evaluation

• Overall MDM Score

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The content captured within each section of the ED MDM note is as follows:

Initial Assessment is foundational, capturing the patient’s chief complaint, medical history, and presenting symptoms, guiding early decisions.

 

ED Course is a dynamic log of the patient’s ED visit, capturing their response to treatments, tests, and interventions. Each entry is timestamped when stated, providing a chronological account of the patient’s progress and the care provided.

 

Final Assessment encapsulates the patient’s status after evaluation and treatment, providing a summary of their current condition and highlighting any resolved or ongoing concerns.

 

Diagnoses include the list of medical diagnoses identified, either confirmed or provisional, based on the clinical discussion and decision verbalized during the patient encounter.

 

Disposition captures the decision on whether the patient will be admitted, discharged, or transferred, based on the clinical discussion and decision verbalized during the patient encounter.

 

Follow-up Instructions records any instructions regarding the diagnosis, treatment plan, and follow-up care, ensuring patient understanding and compliance.

 

Critical Care Time, if mentioned, reflects the time spent on high-level, life-saving interventions, accurately documenting the intensity of care provided.

 

MDM Components Evaluation outlines the complexity of the case, detailing risks, diagnostic uncertainty, and key decisions, which supports billing accuracy by capturing the cognitive effort involved.

 

Overall MDM Score summarizes the complexity of the case, ensuring documentation accurately reflects the level of care provided.