MDM Assistant

Your medical decision-making documentation is where clinical care, billing, and liability intersect. It explains your clinical reasoning, determines the E/M level, and becomes the foundation of your defense if a case ever reaches litigation. It's also the hardest and most time-consuming section to write.

palmER AI's MDM Assistant is built to solve this problem. It takes your chart and generates comprehensive, structured medical decision-making documentation that reflects the full scope and complexity of your clinical reasoning. The tool doesn't just create generic MDM text like the many AI scribes available today. It integrates differential diagnosis analysis, evidence-based recommendations, and risk assessment in a single interface, so you get complete documentation that covers clinical best practices, billing requirements, and medicolegal protection all at once.

palmER's accuracy, structure, and depth of reasoning are unmatched. Your generated MDM includes systematic clinical reasoning, thorough consideration of alternative diagnoses, clear risk stratification, and explicit documentation of your decision-making process. The documentation is more detailed, more structured, and more defensible than that of any other tool on the market today.

🔍 How to Use

What You Get

The MDM Assistant delivers a complete, structured narrative of your case. It captures the full reasoning process: which diagnoses you considered, why you ordered specific tests, and how you arrived at your clinical decision. Each MDM is built to capture the complexity of your clinical reasoning through clear risk stratification. It documents the full complexity of your data review, including labs, imaging, and consultant recommendations. It gets the nuances of your patient's story and documents shared decision making and the thoughtful handling of diagnostic uncertainty and clear return precautions.

The result is documentation that works on three levels at once. It protects you medicolegally by showing systematic clinical reasoning and thorough evaluation. It supports your billing by capturing the true complexity and decision-making difficulty of the case. And it reflects the high quality of care you delivered.

Follow-up Refinements

After generating an MDM, you can use follow-up prompts to:

Revise Content:

• Add discussion of why stroke was considered and ruled out
• Include more detail about the shared decision-making process
• Expand on the rationale for not obtaining CT imaging

Update data:

• Patient's troponin came back at 0.8, update the MDM
• Cardiology recommended admission for cath, revise disposition
• Add the CT results showing no acute findings

Customize Formatting:

Format using this structure:
Chief Complaint:
Problems Addressed:
- Primary Problem:
- Secondary Problems:
- Differential Diagnosis:
Data Reviewed:
- History:
- Nursing notes were reviewed:
- Independent Historian: A discussion was had with an independent historian, [ ], secondary to
[ ]
- Vital Signs:
- Physical Exam Findings:
- Diagnostic Tests:
- Labs (I independently reviewed and interpreted all the blood work and used the
interpretation for my medical decision-making.):
- Imaging (The following radiology tests were ordered and results reviewed by me and
used the interpretation for my medical decision-making):
- EKG:
- Tests considered but not ordered:
- Consultations:
- Prior Records:
Clinical Decision Tools:
Assessment:
Plan:
- Interventions:
- Medications:
- Disposition:
- Follow-Up:
- Return Precautions:
- Patient Education:
- Social Determinants of health that impact treatment or disposition:
- Shared Decision-making:
Risk Assessment:
Medical Complexity:
Billing Codes:
- Suggested E/M Level:
- ICD-10 Codes:
- CPT Codes:

How It Works: Clinical Reasoning at Scale

The MDM Assistant feels less like software and more like having an experienced colleague at your side. You present a case, and the system thinks through it the way you would, flagging the diagnoses that matter and the workup that makes sense.

Differential Diagnosis Made Simple

The Differential Diagnosis panel works quietly in the background generating a thoughtful, clinically grounded differential. You see it organized exactly the way you think: the dangerous things that could kill your patient, as well as the most likely culprits.

Unlike generic differential tools that produce broad, unfiltered lists, palmER AI Suite uses an advanced artificial intelligence engine grounded in Bayesian-style reasoning to analyze each case in context. It interprets findings and distinguishes subtle clinical nuances the way an experienced clinician would, producing focused, high-yield differentials that reflect expert reasoning.

Smart Orders, Not Cookbook Medicine

The Clinical Insights panel provides personalized, context-aware guidance. It analyzes your case to highlight what truly matters for this specific patient. Clinical decision tools such as HEART and PERC scores are applied automatically when relevant. Critical results are flagged, and incidental findings that require follow-up are clearly noted.

The Orders panel builds a complete ED workup tailored to your patient: labs, imaging, medications, monitoring, consultations, and nursing interventions. It supports you on every case, providing confidence that nothing critical is missed.

Your Workflow, Enhanced

Everything integrates into a clean, uncluttered workspace built by physicians who understand what you need to see and when you need to see it.

Just paste in your chart. Within seconds, you get an MDM that reads like you wrote it, because in essence, you did. The AI structures your thinking into documentation that's complete, defensible, and true to the complexity of your medical decision making. When labs come back or consultants weigh in, simple commands like "update with new troponin" or "add cardiology recommendations" reshape the narrative instantly.

This is what documentation should have been all along.

Optimization Strategies

Educational and Quality Applications

A Better Way to Document

The MDM Assistant transforms documentation into a fast, intuitive process. In seconds, you create clear, comprehensive notes that reflect your clinical reasoning and meet the highest standards for billing, compliance, and risk management. The tool captures the true complexity of your cases, supports accurate E/M coding, and ensures your documentation is defensible and thorough. With a streamlined workflow and flexible formatting, you spend less time charting and more time with patients. The MDM Assistant is more than a tool—it is your partner in delivering excellent care and protecting your practice.