MDM Assistant

The MDM Assistant is the most advanced and comprehensive tool in palmER AI Suite. It transforms your chart summary into complete, structured medical decision-making documentation while simultaneously providing intelligent differential diagnosis analysis and evidence-based clinical recommendations—all in one integrated interface.

🔍 How to Use

What You Get

The MDM Assistant automatically generates comprehensive documentation that meets billing and medicolegal standards:

Core MDM Components:

• Structured clinical narrative - Clear, logical presentation of case complexity
• Clinical reasoning documentation - Why you considered certain diagnoses and treatments
• Risk stratification - Patient acuity assessment and complication potential
• Diagnostic uncertainty handling - Thorough assessment of clinical ambiguity when present
• Treatment rationale - Justification for specific interventions chosen
• Shared decision-making - Documentation of patient involvement in care decisions

Billing Support:

• Data complexity documentation - Review of multiple data sources (labs, imaging, consultants)
• Clinical complexity capture - Decision-making difficulty and number of problems addressed
• Risk level assessment - Supports appropriate E/M level and critical care
• Coordination of care - When consultations, transfers, or admissions are involved

Medicolegal Best Practices:

• Systematic thought process - Shows comprehensive clinical reasoning approach
• Alternative diagnosis consideration - Documents evaluation of other possibilities
• Return precautions - Clear instructions for follow-up care and warning signs
• Standard of care compliance - Demonstrates adherence to emergency medicine best practices

Follow-up Refinements

After generating an MDM, you can use follow-up prompts to:

Content Enhancement:

• Add discussion of why stroke was considered and ruled out
• Include more detail about the shared decision-making process
• Expand on the rationale for not obtaining CT imaging

Format Customization:

Format using this structure:
Chief Complaint:
Problems Addressed:
- Primary Problem:
- Secondary Problems:
- Differential Diagnosis:
Data Reviewed:
- History:
- Nursing notes were reviewed:
- Independent Historian: A discussion was had with an independent historian, [ ], secondary to
[ ]
- Vital Signs:
- Physical Exam Findings:
- Diagnostic Tests:
- Labs (I independently reviewed and interpreted all the blood work and used the
interpretation for my medical decision-making.):
- Imaging (The following radiology tests were ordered and results reviewed by me and
used the interpretation for my medical decision-making):
- EKG:
- Tests considered but not ordered:
- Consultations:
- Prior Records:
Clinical Decision Tools:
Assessment:
Plan:
- Interventions:
- Medications:
- Disposition:
- Follow-Up:
- Return Precautions:
- Patient Education:
- Social Determinants of health that impact treatment or disposition:
- Shared Decision-making:
Risk Assessment:
Medical Complexity:
Billing Codes:
- Suggested E/M Level:
- ICD-10 Codes:
- CPT Codes:

Clinical Updates:

• Patient's troponin came back at 0.8, update the MDM
• Cardiology recommended admission for cath, revise disposition
• Add the CT results showing no acute findings

🧠 Differential Diagnosis

The integrated Differential Diagnosis panel provides systematic analysis of potential diagnoses, automatically categorized into "Most Serious (Can't Miss)" and "Most Likely" diagnoses based on your clinical input.

How It Works

As you input clinical information, the system automatically generates:

Most Serious (Can't Miss) Diagnoses:

• Life-threatening conditions requiring rule-out
• High-morbidity diagnoses
• Conditions with time-sensitive treatment windows
• Diagnoses with significant medicolegal implications

Most Likely Diagnoses:

• Statistically probable diagnoses based on presentation pattern
• Common conditions matching symptom constellation
• Diagnoses supported by epidemiological data and risk factors
• Conditions appropriate for initial workup focus

Clinical Applications

Example: 55-year-old male with chest pain

Most Serious:

1. Acute Coronary Syndrome
2. Aortic Dissection
3. Pulmonary Embolism
4. Tension Pneumothorax
5. Pericarditis with Tamponade
6. Esophageal Rupture

Most Likely:

1. Acute Coronary Syndrome
2. Gastroesophageal Reflux Disease
3. Musculoskeletal Chest Pain
4. Anxiety/Panic Attack
5. Pneumonia
6. Costochondritis

🔬 Orders and Recommendations

The Orders panel provides intelligent, evidence-based suggestions for diagnostic workup and treatment plans tailored to your patient's specific presentation.

Intelligent Workup Recommendations

Based on your clinical input, receive prioritized recommendations for:

Immediate Orders:

• STAT testing and time-sensitive interventions
• Critical diagnostic studies that must be completed first
• Emergency medications and treatments
• Monitoring requirements for high-acuity patients

Secondary Assessment:

• Additional diagnostic testing for comprehensive evaluation
• Baseline laboratory studies and imaging
• Risk stratification tools and scoring systems
• Consultation recommendations

Conditional Orders:

• Tests contingent on initial results or clinical findings
• Advanced imaging if first-line studies are inconclusive
• Specialist procedures if conservative management fails
• Alternative diagnostic pathways based on patient response

Evidence-Based Treatment Recommendations

Medication Management:

• First-line therapy selections
• Alternative options for contraindications or allergies
• Drug interaction screening and safety considerations
• Monitoring parameters for high-risk medications

Intervention Planning:

• Procedure indications and timing recommendations
• Monitoring requirements and safety protocols
• Disposition considerations based on treatment response
• Follow-up planning and specialist referrals

🖼️ Integrated Interface Experience

The MDM Assistant interface seamlessly combines all three components:

Main Panel (Center):

• Input field for clinical information
• Generated MDM documentation output
• Editing and customization tools
• Copy/export functionality

Right Sidebar:

• Differential Diagnosis section with Most Serious and Most Likely categories
• Orders section with prioritized recommendations
• Real-time updates based on your clinical input

Workflow Integration:

1. Input clinical data in the main panel
2. Review differential diagnoses in the sidebar for comprehensive consideration
3. Check recommended orders
4. Generate MDM that incorporates insights from all three components
5. Refine and customize using follow-up prompts

✅ Key Benefits

⚡ Efficiency Excellence

• Save time - Complete comprehensive MDM in seconds
• Consistent quality - Maintains high documentation standards
• Integrated workflow - All components work together seamlessly
• Flexible customization - Easily adaptable to your preferred format and style

💰 Billing Optimization

• Higher E/M levels - Better captures medical complexity and decision-making
• Compliance assurance - Meet documentation requirements automatically
• Risk stratification - Demonstrates appropriate complexity for reimbursement

🛡️ Risk Management

• Systematic approach - Structured thinking reduces missed diagnoses
• Comprehensive consideration - Differential analysis shows thorough evaluation
• Clear documentation - Defensible reasoning in medicolegal review
• Evidence-based care - Recommendations follow current guidelines and standards

🎯 Clinical Excellence

• Improved decision-making - Integrated tools enhance clinical reasoning
• Educational value - Helps trainees learn comprehensive documentation
• Quality improvement - Standardized approach supports better care
• Professional development - Continuous exposure to best practices

💡 Optimization Strategies

Input Enhancement Tips

Maximize Clinical Detail:

• Include specific vital signs with trends over time
• Document exact laboratory values and timing
• Note specific physical exam findings and their progression
• Describe patient response to interventions and treatments

Enhance Clinical Context:

• Mention relevant past medical history and medications
• Include social history when pertinent to the presentation
• Note family history if relevant to differential diagnosis
• Document patient concerns and preferences

Workflow Integration

Efficient Documentation Process:

1. Have resulted clinical data before generating MDM
2. Use the HPI and Physical Exam Assistants first for complete clinical picture
3. Review differential and orders
4. Generate and refine MDM with follow-up prompts as needed

Quality Assurance:

• Review generated differential against your clinical thinking
• Verify recommended orders align with your clinical judgment
• Ensure MDM captures your actual decision-making process
• Customize documentation to match your preferences

🚀 Common Use Cases

High-Acuity Presentations

Chest Pain Evaluation:

• Captures ACS risk stratification and workup rationale
• Documents consideration of alternative diagnoses (dissection, PE, pneumothorax)
• Explains imaging and laboratory decision-making
• Supports appropriate disposition and follow-up planning

Altered Mental Status:

• Shows systematic neurologic assessment approach
• Documents consideration of metabolic, toxic, and structural causes
• Explains diagnostic workup sequence and rationale
• Captures family discussion and disposition planning

Dyspnea Assessment:

• Differentiates cardiac vs pulmonary vs other causes
• Documents BNP, chest imaging, and other diagnostic rationale
• Shows treatment response assessment
• Explains admission vs discharge decision-making

Complex Medical Cases

Multiple Chief Complaints:

• Organizes overlapping symptoms into coherent clinical picture
• Prioritizes problems by acuity and significance
• Shows systematic evaluation of each complaint
• Documents resource allocation and time management

Elderly Patients:

• Documents atypical presentation patterns
• Explains family involvement in decision-making
• Shows functional status and cognitive assessment
• Captures polypharmacy considerations and drug interactions

Chronic Disease Exacerbations:

• Differentiates acute from chronic findings
• Documents medication compliance and optimization
• Shows specialist coordination and communication
• Explains changes from baseline and treatment adjustments

🎓 Educational and Quality Applications

Resident Training

Systematic Documentation:

• Demonstrates comprehensive approach to clinical reasoning
• Shows integration of history, physical, and diagnostic data
• Models appropriate differential diagnosis consideration
• Teaches billing and compliance documentation standards

Quality Improvement:

• Standardizes documentation across providers
• Reduces variation in clinical reasoning documentation
• Supports peer review and case discussion
• Enables tracking of diagnostic accuracy and efficiency

Professional Development

Clinical Excellence:

• Exposure to evidence-based diagnostic and treatment approaches
• Continuous learning through guideline integration
• Pattern recognition enhancement through systematic analysis
• Decision-making skill development through structured thinking

Practice Optimization:

• Documentation efficiency improvement
• Billing optimization through appropriate complexity capture
• Risk management through comprehensive documentation
• Patient satisfaction through improved communication and care coordination