The MDM is where clinical reasoning, coding, and risk come together. Paste the chart into palmER and get a complete, defensible MDM in seconds.
Vitals, exam, labs, imaging, consults: the MDM generates from the chart you paste and the details Ambient Scribe captured, so it reflects your actual workup.
Differential, risk stratification, data review, disposition reasoning: organized so a coder, a reviewer (or an attorney) can follow your thinking.
Can't Miss and Most Likely differentials and Clinical Insights generate alongside every MDM, so you can verify your reasoning at a glance.
The chart already contains the workup, results, and disposition. Paste it into palmER to turn that clinical picture into a complete MDM.
The MDM connects the findings to the decisions, documenting what was considered, why orders and consults were needed, and how the disposition was reached.
The MDM note documents the complexity, data, and risk behind the care you provided.
The first element is the number and complexity of problems addressed. The MDM describes the conditions you evaluated, including the serious diagnoses you considered and worked up, so the chart reflects the evaluation rather than only the discharge diagnosis.
Tests ordered and reviewed, external records, independent historians, your own interpretation of an EKG or image, and discussions with consultants all count as data. The MDM states what you reviewed and how it informed the decision instead of leaving it implicit in the orders.
Decisions about hospitalization, parenteral controlled substances, and prescription drug management carry the risk element. The MDM documents the decision you made and why, including shared decision-making and return precautions, so a coder or reviewer can see the risk you managed.
Start a free 30-day trial (no credit card required), paste a chart, and compare the MDM to what you would have written at hour eleven of the shift.
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