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Medical Decision Making Guidelines
Posted: February 17, 2014

# of Diagnoses or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter. For each encounter, an assessment, clinical impression, or diagnosis should be documented as well as decisions regarding management plans and/or further evaluation.

  • Minimal – 1 diagnosis or management option (e.g. Reassured patient)
  • Limited – 2 diagnoses and/or management options (e.g. Cataract, Follow up in six months)
  • Moderate – 3 diagnoses and/or management options (e.g. Cataract, Glare Testing in 3 months; Floaters)
  • Extensive – 4 or more diagnoses and/ or management options (e.g. Cataract, Glare Testing 3 months, new glasses; Floaters, Dilated vitreoretinal assessment 6 months)


The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), diagnostic procedure(s), and possible management options:

  • Minimal – one self-limited or minor problem (e.g. viral conjunctivitis, subconjunctival hemorrhage, floaters, migraine aura)
  • Low – two or more self-limited or minor illness; one stable or chronic illness; one acute illness or injury; acute uncomplicated injury or illness (e.g. minor cataract, corneal abrasion, PVD, treated retinal hole, amblyopia, blepharitis; or combination of two lesser self-limited ocular problems)
  • Moderate – One chronic illness with mild complication(s); Two stable chronic illnesses; An undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury (e.g. strabismus and amblyopia of moderate degree, early AMD, advancing cataract, non-proliferative diabetic retinopathy, glaucoma without advanced field loss, loss of vision or visual ability, suspected multiple sclerosis, suspected diabetes with myopic shift, lid laceration, iritis; or combinations of two lesser and chronic ocular problems)
  • High – One or more chronic illness with severe complications; Acute or chronic illness or injuries posing a threat to life; Abrupt change in neurological status (e.g. cataract, glaucoma, or AMD with advanced vision loss, CRAO/fleeting blindness, proliferative diabetic retinopathy, choroidal melanoma)


The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered and reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed. Discussion of contradictory or unexpected test results is an indication of complexity. Reviewing a test report or interpretation is another indication of complexity. The options include:

  • Minimal – (e.g. no significant record review and minimal diagnostic testing review)
  • Limited – (e.g. limited record review and/or limited diagnostic testing review )
  • Moderate – (e.g. moderate record review and/or moderate diagnostic testing
    review )
  • Extensive – (e.g. extensive record review and/or extensive diagnostic testing review)





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