A five-step approach to documenting uncertain diagnoses

While most notes include the elements necessary for code selection, some do not illuminate why certain decisions were reached or why a particular treatment or testing plan was justified. Yet disciplined note construction is critical to effective communication between physicians and may also contribute to clearer medical decision making. When documenting an unconfirmed or symptom-based diagnosis, try this five-step approach for producing notes that facilitate better follow-up care – your colleagues’ and your own:

1. Commit to a diagnosis. Explain why, among the various differential options, you suspect this diagnosis is most likely.

2. List testing you plan to use to confirm or rule in the working diagnosis.

3. List empiric or symptomatic treatment.

4. List less likely diagnoses. Explain why they are not as probable and how you will rule them out.

5. Define the parameters for reviewing the evaluation and treatment response.

Consider these examples:

• Rash: Suspect allergic photodermatitis given location in sun-exposed areas and onset after use of new sunscreen lotion. Confirm by stopping lotion. Treatment: PABA-free sunscreen. Doubt lupus given no prior history and absence of other complaints. Doubt prescription medications due to no admitted use. Return to clinic if symptoms persist after lotion change.

• Abdominal pain: Suspect biliary dyskinesia due to epigastric location, relation to fatty meals, body habitus and negative right-upper-quadrant ultrasound for gallstones. Confirm with cholescintigraphy (HIDA). Treatment: fatty food avoidance. Doubt pancreatitis given nondrinker and negative ultrasound, but rule out with amylase/lipase. Doubt gastroesophageal reflux disease (GERD) given proton-pump inhibitor use and contrast to usual GERD symptoms. Return to clinic after HIDA scan and consider surgery consult.

Adapted from "Structure and Synchronicity for Better Charting."