The Diagnostic Process

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The Diagnostic Process

Every member of the clinical team, including patients and family, has a role to play in ensuring that diagnoses are accurate, timely and communicated to the patient. The Diagnostic Process Map is a resource developed by the National Academies of Sciences, Engineering, and Medicine (National Academies) and offered by the Society to Improve Diagnosis in Medicine (SIDM) to help everyone understand and work to improve the diagnostic process.

To navigate through the chart, please click on the chart, or scroll down on phones.

As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

The diagnostic process is a complex and collaborative activity that unfolds over time and for most patients occurs within the context of a health care work system. This diagram and the ones that follow show typical elements of the diagnostic process, although for some patients certain steps may be skipped, or the order may be re-arranged. Some problems may be recognized immediately, for other problems the diagnostic process needs to play out before a diagnosis can be reached, and this timeline is different for every disease and for every patient. Health problems that are rare or especially complicated may take longer to diagnosis, and some problems may never be diagnosed. Although ‘the earlier the better’ is typically the best hope for diagnosis, sometimes a ‘test of time’ allows symptoms or signs to become more specific, and may be the best course of action.


Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

 

 

Patient Experiences a Health Problem

First, a patient experiences a health problem. Often, if we have a new symptom, we may try to diagnose the problem on our own, and if we are satisfied with the answer, that may be the end of the diagnostic process. Many patients will also share their health concerns with family and friends for their input on what’s wrong, or consult online resources, their pharmacist, or other people they believe may help. Patients understand and verbalize their complaints in their own words and in their own ways. The variability in how a patient experiences and describes their problem contributes to the complexity of the diagnostic process.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Patient Engages with Health Care System

The decision to engage in the healthcare systems is complicated and influenced by many factors beyond experiencing symptoms, some of those factors are related to access, cost and trust in the system. But, once a patient decides to seek health care, this will initiate the more formal process of arriving at a diagnosis, which will vary depending on the problem, and the type of provider or healthcare entity involved. Aside from widely recognized signs of a serious problem such as chest pain, difficulty breathing, or double vision, there is no good guidance on what problems can be handled at home; use your best judgment, and when in doubt, check with your healthcare provider.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Information Gathering

Diagnosis depends on the the patient and clinician partnering to translate the patient’s complaints and concerns into medical concepts. This begins with the patient sharing their clinical history, and the physician conducting a physical examination. The patient’s report of symptoms (what they say) and signs (findings from a physical exam) comprise the two main elements that most inform a diagnosis. Information from a patient’s past medical history, their family or social situation, their diet, and other sources may also be relevant to the diagnosis.

Many experts have said that in most situations the diagnosis can be determined from the history and physical alone. In other cases, it may be necessary to order diagnostic laboratory tests or imaging studies. This is all part of the information gathering that allows clinicians and patients to come to an accurate diagnosis.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Information Integration & Interpretation

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 a patient’s signs and symptoms. While clinicians engage in this information processing activity to develop a working diagnosis, it is important for them to discuss with the patient how and why their symptoms fit together to inform that working diagnosis, and to ask the patient for input.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Working Diagnosis

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, and that other diseases haven’t been ruled out. Typically, clinicians will consider more than one diagnostic hypothesis or possibility as an explanation of the patient’s symptoms and will refine this list as further information is obtained in the diagnostic process, eventually coming to a “working diagnosis.”

The working diagnosis should be shared with the patient, including an explanation of the degree of uncertainty associated with a working diagnosis. Each time there is a revision to the working diagnosis, this information should be communicated to the patient, with opportunity for input and discussion.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Has sufficient information been collected?

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 map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

  • Clinical History & Interview

    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 history already contained in the patient's medical record are accurate. A patient's clinical history includes documentation of the current concern, past medical history, family history, social history, and other relevant information, such as current medications (prescription and over-the-counter) and dietary supplements.

    The process of acquiring a clinical history and interviewing a patient requires effective communication, active listening skills, and tailoring communication to the patient based on the patient's needs, values, and preferences.


    As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

    Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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  • Physical Exam

    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 interactions with the patient.

    A physical exam may include an analysis of many parts of the body, not just those suspected to be involved in the patient's current complaint. A careful physical exam can help a clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing, and can aid in building trust with the patient (Verghese, 2011).


    As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

    Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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  • Referral & Consultation

    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 can refer the patient to a clinician who holds more suitable expertise. Clinicians can also recommend that the patient seek a second opinion from another clinician to verify their impressions of an uncertain diagnosis or if they believe that this would be helpful to the patient. Patients may independently choose to seek a second opinion if they feel their initial diagnosis may not be right.


    As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

    Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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  • Diagnostic Testing

    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 attack in a patient with chest pains. There are many important forms of diagnostic testing including laboratory medicine, anatomic pathology, medical imaging and others.


    As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

    Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Communication of the Diagnosis

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 mentioned, and these may be narrowed down over time by further testing, or consultation, or by waiting to see if the symptoms and signs worsen or improve, or if new ones arise. Medical terms may be used, but it is important that the explanation also be presented in terms the patient can understand. Clinicians should check with the patient to see if they understand the diagnosis and if they have any questions and understand the necessary next steps.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Treatment

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 National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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Outcomes

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 the process going forward.


As you are discussing diagnostic errors, this PowerPoint presentation can help you map errors against the National Academies of Sciences, Engineering, and Medicine (National Academies) diagnostic process diagram and discuss drivers of errors and steps that could prevent future errors. Feel free to download and use. For instructions on using the PowerPoint, watch our video tutorial.

Used and adapted with permission. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794. Diagram can be found on p 3 of the report.

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