The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected determining the final score.
Level of Risk
Diagnostic Procedure(s) Ordered
One self-limited or minor problem (cold, insect bite)
Lab tests req. venipuncture
Ultrasound, e.g., Echocardiography
Two or more self-limited or minor problems
One stable chronic illness, e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH
One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, e.g., lump in breast
Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis
Acute complicated injury, e.g., head injury with brief loss of consciousness
Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization
Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or dislocation without manipulation
One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acuterenal failure
An abrupt change in neurologic status, e.g., seizure, TIA, weakness, sensory loss
Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological tests
Diagnostic Endoscopies with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors
Emergency major surgery (open, percutaneous or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis
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