Avoid using any loaded or judgmental language. The patient’s integrity matters, and you don’t want anyone reading the chart to judge the patient unfairly. If you’re lucky enough to have a medical scribe, communicate what you’re doing verbally while you’re doing it—the scribe will write everything down for you.
You may get a diagnosis just from doing this. If your patient says their foot hurts because a car ran over it, and you can see the bone protruding from the skin on their foot, you can reasonably say the patient broke a bone in their foot. Ask follow-up questions as needed based on your specialty and knowledge. Take your experience into account here. If you’ve seen these symptoms somewhere else before, use that knowledge to guide you.
Follow these chronologically backwards from the initial visit throughout the patient’s history to confirm any tie-in of symptoms. Eliminate diagnoses that do not fit your patient based on their symptoms and history.
The tests you choose are going to depend entirely on your specialty, but generally speaking, you should work from general diagnostic tests to more specific tests.
You may go through multiple diagnoses before you actually identify the proper disease or condition.
From here on out, it’s all about reframing and revising your working diagnosis until you have enough evidence to reasonably confirm your suspicion.
Refer the patient to specific specialists whom you know to be adept and easy to work with. If you find yourself wondering whether a referral is necessary or not, just refer the patient. It’s better to be safe than sorry, and a second set of eyes is often very helpful.
Point out the tests that were already performed to show the reason for the problem. Explain how these evaluations confirmed your diagnosis and show conclusive evidence. Use factual information, such as test result quotes, to back up your identification of the patient’s issue. Identify the organic issues (if any) that influenced the decision for this diagnosis.
If you confirm your working diagnosis, great! Move on to treatment and explain the prognosis for the patient. If you end up ruling out your working diagnosis, the entire process starts back over again. Use what you learned up to this point to inform your new working diagnosis and continue to gather more information. This entire process can take 3 minutes if it’s straightforward. However, it can take months depending on how complex or elusive the underlying problem is.
If the patient is in denial, you can always suggest they get a second opinion. Doing nothing is also an option depending on the issue. “This should go away on its own” is a totally valid course of action.
