Do Not Confuse Assessment with Diagnosis
Though the diagnosis and treatment plan are a portion of the assessment, they are not the same. The assessment and the diagnosis go hand in hand, with the diagnosis delivering your “standard English” wording of what is actually wrong with your patient. This diagnosis is the basis for your treatment recommendations for care of your patient, and it establishes the medical necessity and clinical appropriateness of your recommended treatment plan.
Selection of the Appropriate Diagnosis for Chiropractic Documentation
Review your patient’s presenting condition, subjective and objective findings, and as you assess and correlate the information provided excluded diagnoses that are not supported. Consider each condition diagnosed, documenting underlying issues with clear, well-written documentation to support your final patient diagnoses.