Title: Module 5 Introduction: (CU2 M5) The Medical Record and the MDM
Course: SkillsCom CMA 111 16.0 > Section: Credit Unit 2 Module 5

A patient encounter requires the provider to make medical decisions also known as medical decision making (MDM).  A patient's medical record is required to demonstrate and document those medical decisions.  The documentation must stratify the medical decisions based on complexity.  A coder based on documentation will "code" the level of complexity based on the following:

- The nature and number of clinical problems
- The amount and complexity of the data reviewed by the physician
- The risk of morbidity and mortality to the patient

Module Outcomes:

- Define MDM
- List the 11 Organ Systems
- List the 7 or 10 Body Areas
- List the 9 Methods of Exam
- Describe how "The Exam" is included in the medical documentation.