1 | Gathering additional information | Decision to obtain information from other source than patient interview, physical examination and patient chart; ordering new tests/diagnostic procedures for the patient, actively seeking external information from other party (other hospital, general practitioner, family member and so on) or discussing patient with other physician or healthcare personnel. | ‘I am going to order an MRI of your skeleton’. |
2 | Evaluating test result | Simple, normative assessments of clinical findings and tests. | ‘Your blood pressure is high. 180/100 is high’. |
3 | Defining problem | Complex, interpretative assessments that defines what the problem is and reflects a medically informed conclusion, thereby being either a diagnostic conclusion, an evaluation of state of health, an aetiological inference or a prognostic judgement. | ‘This is basically what we call osteoarthritis’. |
4 | Drug related | Decision to start, refrain from, stop, alter or maintain a drug regimen. | ‘I will give you a four day treatment of dexametasone’. |
5 | Therapeutic procedure related | Decision to intervene on a medical problem, plan, perform or refrain from therapeutic procedures of a medical nature. | ‘We cannot operate more on you’. |
6 | Legal and insurance related | Medical decision concerning the patient, which is based on or restricted by a legal regulation or financial arrangements. | ‘I will write you a sick leave note’. |
7 | Contact related | Decision regarding admittance or discharge from hospital, scheduling of control and referral to other part of the healthcare system. | ‘She is so weak that she should be admitted’. |
8 | Advice and precaution | Decision to give the patient advice or precaution, thereby transferring responsibility for action from provider to patient. | ‘You should stop smoking completely’. |
9 | Treatment goal | Decision to set defined goal for treatment and thereby being more specific than giving advice. | ‘We want to get the A1c down between 7 and 8’. |
10 | Deferment | Decision to actively delay decision or a rejection to decide on problem presented by patient. | ‘You have to discuss this with your family doctor’. |