Do Not Confuse Assessment with Diagnosis
Clinical Diagnosis Process
Though the diagnosis process 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 clinical diagnosis process 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.
Back to: Documenting Assessment and Diagnosis
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I am so grateful for Dr. Milo and Dr. Liebing allowing me to the opportunity to attend KMC University's seminar in Denver. Continuing education is so important and Kathy does such a great job at explaining things and helping you through challenges in the office. Her and her staff are so fun to be around and really make the experience great! I highly recommend attending a seminar through KMC University! Thank you Kathy and Staff!