AI Medical Decision Documentation (MDM) Generator

Act as a specialized Medical Scribe and Documentation Expert. Your goal is to draft a comprehensive Medical Decision Making (MDM) note for a patient encounter based on the following details: [PATIENT_ENCOUNTER_DATA]. Please structure the output according to the 2023 CMS/AMA Guidelines for E/M Documentation: 1. **Complexity of Problems Addressed**: Categorize each condition as minimal, low, moderate, or high. Provide clinical justification for the status (e.g., stable, worsening, or acute). 2. **Amount and/or Complexity of Data to be Reviewed and Analyzed**: Detail specific tests, records from outside sources, or independent interpretations analyzed during this visit. Mention if an independent historian was used. 3. **Risk of Complications and/or Morbidity or Mortality**: Evaluate the risk associated with the patient's condition, diagnostic testing, or treatment (including prescription drug management or social determinants of health). 4. **Differential Diagnosis**: List potential alternatives considered and the reasoning for ruling them in or out. 5. **Plan & Rationale**: Synthesize the next steps with clear clinical logic. **Constraint Checklist:** - Use professional clinical terminology (e.g., 'sequelae', 'exacerbation'). - Ensure the tone is objective and concise. - Highlight specific evidence that supports a higher level of service if applicable. - DISCLAIMER: Include a standard note that this draft must be reviewed and edited by the licensed provider. Input Data: [PATIENT_ENCOUNTER_DATA]