Practical Documentation: Documenting your diagnosis

Published: 2010-07-04 18:20:49
Author: Kathy Mills Chang | ChiroEco | March 2010

Wikipedia defines a differential diagnosis as a systematic method used to identify unknowns.

This method, essentially a process of elimination, is used by physicians and other qualified healthcare professionals to diagnose a specific disease in a patient. Not all medical diagnoses are differential ones. Some diagnoses merely name a set of signs and symptoms that may have more than one possible cause, and some diagnoses are based on intuition or estimations of likelihood.

Careful differential diagnosis involves first making a list of possible diagnoses, then attempting to remove diagnoses from the list until — at most — one diagnosis remains. Removing diagnoses is done by making observations and using tests that should have different results, depending on which diagnosis is correct.

Differential diagnosis is the process whereby a given condition or circumstance (called the presenting problem or chief complaint) is examined in terms of underlying causal factors and concurrent phenomena, and is then compared to known categories of pathology or exceptionality.

Differential diagnosis allows the physician to:

• More clearly understand the condition or circumstance,

• Assess reasonable prognosis, and

• Plan treatment or intervention for the condition or circumstance.

The diagnosis is a synthesis of your test results. The findings that differentiate one diagnosis from another are referred to as clinical pearls.

As a physician, you are expected to make “the diagnosis to your highest level of understanding,” says Manuel Duarte, DC, full-time faculty member at National University of Health Sciences.

It is OK to have intersegmental dysfunction as a diagnosis, but this is a part of the bigger clinical conundrum. A higher level of diagnosis could be something such as lumbar disc herniation with concomitant sciatica and associated segmental dysfunction as a descriptor.

Your review of the patient’s historical information, physical examination, and x-ray findings are the building blocks to your diagnosis. What makes a great physician is the ability to synthesize this information and interpret it. The end result is an identification of the injured tissue and the extent of the injury. With application of this process, the treatment should be intuitive.

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