Emergency Department Medical Decision-Making for NPs/PAs: Your Brain At Work

K. Sue Hoyt


Sheila Sanning Shea

Sheila Sanning Shea , RN, MSN, ANP, CEN


Published March 20, 2014

Nurse practitioners (NPs) and physician assistants (PAs) are now an integral part of the U.S. healthcare system and have assumed a major role in both primary care and some specialty care areas. Like our physician colleagues, we have encountered increasing expectations to "do more with less" (i.e., see more and sicker patients and provide quality, comprehensive care in less time — all while meeting challenging national metrics).

As the number of NPs and PAs working in emergency medicine and other episodic care settings increases, it is essential that these professionals master the medical-decision making (MDM) process to justify the degree and complexity of each patient encounter.

As PA/NPs, MDM compliments our existing clinical assessment skills and helps us to provide the best quality care for our patients. Mastering MDM also helps ensure that our hospitals and practices are appropriately reimbursed by documenting both medical necessity and effort expended in patient care.

A detailed and defensible MDM is the cornerstone of a well-constructed medical record. However, until recently, relatively few PA/NP training programs emphasized MDM, which is grounded in the medical model. For this reason, PA/NPs who are new to the emergency setting may benefit from additional training, practice and access to decision-making tools.

The good news is that PA/NPs are "critical thinkers" and can easily make the paradigm shift to include medical decision making in their thought process and plan of patient care. In this post, we'll provide an overview of the MDM process as well as some suggestions for practitioners who wish to sharpen their skills.

What Is MDM?

MDM is the process by which the NP/PA highlights the amount of "brain power" that was expended during the care of the patient. Both potential and actual problems must be taken into account. These problems are then considered in light of patient comorbidities and risk factors so that an appropriate plan of care can be developed.

For example, even seemingly innocent complaints such as a viral upper respiratory infection (e.g., cold) can have the potential for serious diagnoses that were overlooked or not considered, especially in the pediatric patient. Complications such as the risk of respiratory distress or airway obstruction must be included in the MDM.

In every patient encounter, the NP/PA must efficiently gather adequate data to formulate an "educated guess" and rapidly consider many "possible or probable" diagnoses to reach the most likely conclusion regarding the patient's condition. This MDM process requires deliberate thought and a high level of cognitive function to process and analyze data and draw conclusions.

Consider the following common scenario of a young man with a hand laceration after punching a window. Based on the history and physical examination, the NP/PA orders a hand radiograph to confirm the diagnosis of fracture or retained foreign body. Although seemingly straightforward, this clinical encounter actually requires a considerable degree of cognitive effort that must be documented in the medical record. In this case scenario, thorough documentation of the MDM should include:

Why a test was ordered. A radiograph was needed to rule out fracture or possible foreign body.

Results of the test and implication of the outcome. The radiograph was positive for a fracture of the fifth metacarpal and negative for foreign body. The patient has an open fracture, which is clinically important because of increased risk of infection and inherently more complicated care requiring close follow-up.

Other potential problems that were considered. Although a simple laceration is the obvious diagnosis, other possible causes of the patient's problems include open fracture, retained foreign body and tendon or joint involvement.

Patient response to course of care. Rather than a laundry list of actions, this portion of the MDM process is an opportunity to highlight all diagnostic decisions that were considered and interventions that were undertaken to investigate the actual and potential causes of a patient's problem. It also details all therapeutic interventions and describes the patient responses, including a lack of improvement that required a change in the clinical course of action.

Example: MDM/Differential Diagnosis for cough/shortness of breath (SOB)

Here is a sample of what the provider must consider and document:

  • Potential diagnoses for cough and SOB range from benign and self-limiting problems such as upper respiratory infection (URI) or mild asthma to respiratory failure. Common causes are bronchitis or pneumonia or exacerbation of asthma/chronic obstructive pulmonary disease (COPD).
  • Cardiac-related SOB must be considered in patients with significant medical problems.
  • Sudden, severe chest pain/SOB with pain radiating to the abdomen/back may indicate abdominal aortic aneurysm (AAA)/thoracic aortic dissection (TAD).
  • Spontaneous pneumothorax is more common in younger adults who are thin, smokers, or people who have Marfan's syndrome.
  • Pulmonary embolus (PE) can present with a wide range of symptoms. It may be very subtle and should be included in every evaluation of chest pain/SOB.
  • Foreign body (FB) aspiration may occur in children and aspiration pneumonia in elders.
  • Children must be carefully evaluated for respiratory fatigue and impending respiratory failure.

Aids to Decision-Making

In response to evolving roles within the profession, more and more PA/NP training programs are offering explicit instruction in MDM. Practicing professionals who are learning and refining the process may benefit from decision support tools like charts and worksheets. In addition, many electronic health records integrate MDM tools.

Of course, as the above example demonstrates, the thinking involved in MDM can be quite complex. As educators, we saw the need for more in-depth tools to guide the process. This led us to create the first Emergency Pocket Reference Guide for PAs, NPs and other medical professionals. To learn more or purchase a copy, visit www.mypocketguru.com or find us on Amazon.com.

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