The outcomes of the diagnostic process are extremely important to you! Was the health problem identified? Did your symptoms and signs resolve? Have any new signs or symptoms appeared? What was the impact of the illness (physical, emotional, financial)? The outcomes are also valuable to help providers, practices, and healthcare organizations learn how to improve…

This is the planned path of care based on the diagnosis. Sometimes this may be a treatment trial if the diagnosis isn’t certain, and other times it may be appropriate to defer specific treatment until the diagnosis is more certain. As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the…

A required element of the diagnostic process is to communicate to the patient an explanation of their health problem. Sometimes this will be a single diagnosis. Other times it may be a class or category within a broader health issue, like ‘you have an upper respiratory tract infection’. Or, several different diagnostic possibilities may be…

Diagnostic testing may occur in successive rounds of information gathering, integration, and interpretation, as each round of information refines the working diagnosis. In many cases, diagnostic testing can confirm a diagnosis that is suspected on the basis of the history and physical examination, such as obtaining an electrocardiogram to confirm the diagnosis of a heart…

Clinicians may refer to or consult with other clinicians (formally or informally) to seek additional expertise about a patient’s health problem. The consult may help to confirm or reject the working diagnosis or may provide information on potential treatment options. If a patient’s health problem is outside a clinician’s area of expertise, he or she…

The physical exam is a hands-on observational examination of the patient. First, a clinician observes a patient’s demeanor, complexion, posture, level of distress, and other signs that may contribute to an understanding of the health problem (Davies and Rees, 2010). If the clinician has seen the patient before, these observations can be weighed against previous…

Acquiring a clinical history and interviewing a patient provides important information for determining a diagnosis and also establishes a solid foundation for the relationship between a clinician and the patient. An appointment begins with an interview of the patient, when a clinician compiles a patient’s medical history or verifies that the details of the patient’s…

Patients have a legal right to access their medical records and examine the information that is collected through clinical history, interview, tests and referrals. Often these are available through patient portals. If not, patients can ask for copies of their medical records and notes. As you are discussing diagnostic errors, this PowerPoint presentation can help you…

The clinician will often consider a list of potential diagnoses (a differential diagnosis) when attempting to determine the cause of a patient’s presentation. The differential diagnosis represents a prioritized list of the top possibilities. Sometimes the most likely choice is designated to be the working diagnosis, meaning that it is likely, but hasn’t been confirmed,…

The healthcare provider will use their knowledge of medicine to interpret all of the information that has been gathered and try to identify patterns that suggest a certain disease or a type of disease. There are only 200-some symptoms, but over 10,000 diseases, so there are typically many different possible diseases that could account for…