What is a working diagnosis?
The working diagnosis may be either a list of potential diagnoses (a differential diagnosis) or a single potential diagnosis. 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. 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. As the diagnostic process proceeds, a fairly broad list of potential diagnoses may be narrowed into fewer potential options, a process referred to as diagnostic modification and refinement (Kassirer et al., 2010). As the list becomes narrowed to one or two possibilities, diagnostic refinement of the working diagnosis becomes diagnostic verification, in which the lead diagnosis is checked for its adequacy in explaining the signs and symptoms, its coherency with the patient's context (physiology, risk factors), and whether a single diagnosis is appropriate. When considering invasive or risky diagnostic testing or treatment options, the diagnostic verification step is particularly important so that a patient is not exposed to these risks without a reasonable chance that the testing or treatment options will be informative and will likely improve patient outcomes.
What is diagnostic in health care?
Diagnosis has been described as both a process and a classification scheme, or a “pre-existing set of categories agreed upon by the medical profession to designate a specific condition” (Jutel, 2009).1 When a diagnosis is accurate and made in a timely manner, a patient has the best opportunity for a positive health outcome because clinical decision making will be tailored to a correct understanding of the patient's health problem (Holmboe and Durning, 2014). In addition, public policy decisions are often influenced by diagnostic information, such as setting payment policies, resource allocation decisions, and research priorities (Jutel, 2009; Rosenberg, 2002; WHO, 2012).
What is the importance of clinical history?
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. A common maxim in medicine attributed to William Osler is: “Just listen to your patient, he is telling you the diagnosis” (Gandhi, 2000, p. 1087). 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.
What are the four types of information gathering activities in the diagnostic process?
The committee identified four types of information-gathering activities in the diagnostic process: taking a clinical history and interview; performing a physical exam; obtaining diagnostic testing; and sending a patient for referrals or consultations.
What is the purpose of a clinical history interview?
Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient's health problem.
How to obtain a clinical history?
The National Institute on Aging, in guidance for conducting a clinical history and interview, suggests that clinicians should avoid interrupting, demonstrate empathy, and establish a rapport with patients (NIA, 2008). Clinicians need to know when to ask more detailed questions and how to create a safe environment for patients to share sensitive information about their health and symptoms. Obtaining a history can be challenging in some cases: For example, in working with older adults with memory loss, with children, or with individuals whose health problems limit communication or reliable self-reporting. In these cases it may be necessary to include family members or caregivers in the history-taking process. The time pressures often involved in clinical appointments also contribute to challenges in the clinical history and interview. Limited time for clinical visits, partially attributed to payment policies (see Chapter 7), may lead to an incomplete picture of a patient's relevant history and current signs and symptoms.
Why is imaging not useful?
Imaging may fail to provide useful information because of modality sensitivity and specificity parameters; for example, the spatial resolution of an MRI may not be high enough to detect very small abnormalities. Inadequate patient education and preparation for an imaging test can also lead to suboptimal imaging quality that results in diagnostic error.
What is medically necessary in 2020?
Updated on September 27, 2020. Health insurance plans provide coverage only for health-related serves that they define or determine to be medically necessary. Medicare, for example, defines medically necessary as: “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards ...
What to do if you are not sure about your health insurance?
If you are not sure, call your health plan’s customer service representative. It's also important to understand any rules your health plan may have regarding pre-authorization.
What does health insurance cover?
Health insurance plans provide coverage only for health-related serves that they define or determine to be medically necessary.
What is the Patient Advocate Foundation?
Patient Advocate Foundation. A patient's guide to navigating the insurance appeals process.
What is an appeals process for health insurance?
Health plans have appeals processes ( made more robust under the Affordable Care Act) that allow patients and their healthcare providers to appeal when a pre-authorization request is rejected or a claim is denied. 14
Does Verywell Health use peer reviewed sources?
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Do you need to get preauthorization before a non emergency procedure?
Your plan might require you and your healthcare provider to get approval from the health plan before a non-emergency procedure is performed—even if it's considered medically necessary and is covered by the plan—or else the plan can deny the claim. 13
When should a surgical or invasive diagnostic procedure be documented?
Documentation guideline: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
What is the documenting guideline?
Documentation guideline: For each encounter, an assessment, clinical impression or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
What is MDM in medical?
The Medical Decision Making (MDM) of an evaluation and management (E/M) visit is one of the three components of determining the level of a patient’s visit. But the MDM can sometimes be the most difficult component, as this is where the provider’s thought process is quantified in deciding the correct level of E/M service. In the American Medical Association Current Procedural Terminology (CPT) manual, the level of complexity of MDM is considered to be a function of three variables, which are also reflected in the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management Services:
What should be documented in E/M?
Documentation guideline: If a diagnostic service (test or procedure) is ordered, planned, scheduled or performed at the time of the E/M encounter, the type of service (e.g., lab or X-ray), should be documented. Documentation guideline: The review of lab, radiology and/or diagnostic tests should be documented.
What are the factors that increase the complexity of medical decision making?
Documentation guideline: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity and/or mortality should be documented.
What is the documenting guideline for a family history?
Documentation guideline: Relevant finding from the review of old records and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient.
What should the record indicate when a referral is made?
Documentation guideline: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where referral or consultation is made or from whom the advice is requested.
Why is incompetency considered labor intensive?
Because an adjudication of incompetency effectively denies an individual autonomy to make decisions, such court cases become labor intensive. An individual is presumed to be competent unless demonstrated to be otherwise. The standard of proof required for judicial finding of incompetency is that of “clear and convincing evidence.”6This standard of proof, based on evidence presented by licensed health care practitioners and others, is set at a standard between the high level of proof required for criminal convictions, i.e., “beyond a reasonable doubt,” and the lowest standard of “preponderance of the evidence.”7
What is the mental status test?
Often, psychiatrists will conduct a mental status examination, such as the Folstein Mini-Mental Status Examina tion,32the Short Portable Mental Status Question naire,33and the Cognitive Capacity Screening Examination,34to have a more formal measure of the patient's ability to manipulate information. Such tests measure cognitive abilities, but not decision-making capacity. Scores yielded by such instruments provide an indication of severity of dementia, but cannot yield a score for and lack sufficient sensitivity for decision-making capacity.35,36It is possible that an educationally disadvantaged person scoring poorly on the Mini-Mental Status Examination or alternative test can retain an ability to make treatment decisions, while a highly educated person adept at responding to the test's questions can fail to make prudent treatment decisions.37Dementia and cognitive deficits, e.g., mild mental retardation, may not necessarily preclude decision-making capacity.38
What is competency in law?
Competencyis a legal term referring to individuals “having sufficient ability… possessing the requisite natural or legal qualifications” to engage in a given endeavor.2(p257)Unfortunately, this definition is a broad concept encompassing many legally recognized activities, such as the ability to enter into a contract, to prepare a will, to stand trial, to make medical decisions, and so on. The definition, therefore, must be clarified depending on the issue in question. Simply put, competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally.3The determination of incompetence is a judicial decision, i.e., decided by the court. An individual adjudicated by the court as incompetent is referred to as de jure incompetent. After determining that the de jure incompetent cannot make prudent decisions in his or her own best interest, the court will assign a guardian to make decisions on the person's behalf.4,5
What are systemic lines of inquiry?
Systematic lines of inquiry can tap into risks and benefits, for example, “What can happen to you if you have the surgery?” “What is your understanding of the side effects of this particular medication?” or “The proposed test carries some risks; can you indicate what they are?” Frame questions assessing the benefits of the proposed interventions in a similar fashion and attend to the patient's understanding of probabilities of favorable or unfavorable outcomes.26Patients may well understand the reasons for the proposed procedure and how it is conducted, but may distort the likelihood of success or deny likely untoward or adverse consequences.
What is appreciation assessment?
The concept of appreciation is a rather individualized component of the capacity assessment. Assessment of the patient's ability to appreciate is not based upon the comparison of the patient's expressed wishes against the standard of what most reasonable persons would endorse in that situation. It does involve an appreciation of how the individual values each risk and benefit of the proposed treatment in question. Severe denial as a defense mechanism, delusions, or other psychotic processes can impair appreciation.30,31
What is capacity in medical terms?
Capacity refers to an assessment of the individual's psychological abilities to form rational decisions, specifically the individual's ability to understand, appreciate, and manipulate information and form rational decisions. The patient evaluated by a physician to lack capacity to make reasoned medical decisions is referred to as de facto incompetent, i.e., incompetent in fact, but not determined to be so by legal procedures. Such individuals cannot exercise the right to choose or refuse treatment, and they require another individual, a de facto surrogate, to make decisions on their behalf.
How to assess a patient's condition?
Making certain that a patient understands his or her condition can be best assessed by open-ended inquiry, for example, “Can you tell me what your medical problem(s) consists of?” or “Why have you been brought to the hospital?” Avoid questions that elicit a yes or no reply, e.g., “Do you understand what your medical condition is?” since an affirmative reply does not clearly convey that the person comprehends the nature of the illness.
Why is it so hard to find an unbiased expert willing to testify against a negligent doctor?
Because doctors are often reluctant to testify against their colleagues (referred to by lawyers as the "conspiracy of silence"), it may be difficult to find an unbiased expert willing to testify against a negligent doctor regarding sub-standard care.
What is the purpose of standard of care in medical malpractice?
The purpose of the standard of care in a medical malpractice case is to determine whether a doctor acted in a manner consistent with the expectations of the medical community. If a doctor did not do what is expected of someone in his or her field, the doctor may be held liable for any harm that comes from not adhering to those standards.
What is a CPR general practitioner?
Thus, a general practitioner who has administered sub-standard cardio-pulmonary resuscitation (CPR) to a heart attack victim (who subsequently dies as a result of the sub-standard care) ...
What is the standard of care?
Standard of Care: Treatment and Surgery. The standard of care owed to patients is the level of skill, expertise, and care possessed and practiced by physicians in the same or similar community, and under similar circumstances. At one time, the standard of care was based on what other doctors do in a specific geographic location.
Is the standard of care based on what other doctors do?
At one time, the standard of care was based on what other doctors do in a specific geographic location. Rural doctors could be given more leniency than urban doctors. However, the advent of "national board" exams for new doctors and "board certifications" for doctor-specialists has resulted in a more uniform and standard practice ...
Can you sue a doctor for negligence?
Outcomes are never guaranteed, but if your doctor has not provided the standard of care required by law, you may sue the doctor (and perhaps other defendants) for negligence. The first step is to find the right attorney.
Can a doctor be held responsible for a high dose?
For example, if the medical community has a generally accepted maximum dose for a medication, and the doctor administers a dose that exceeds that limit, the doctor can be held responsible for harm the patient suffers due to the high dosage.
What are the rights of a patient who refuses treatment?
In addition, there are some patients who do not have the legal ability to say no to treatment. Most of these patients cannot refuse medical treatment, even if it is a non-life-threatening illness or injury: 1 Altered mental status: Patients may not have the right to refuse treatment if they have an altered mental status due to alcohol and drugs, brain injury, or psychiatric illness. 6 2 Children: A parent or guardian cannot refuse life-sustaining treatment or deny medical care from a child. This includes those with religious beliefs that discourage certain medical treatments. Parents cannot invoke their right to religious freedom to refuse treatment for a child. 7 3 A threat to the community: A patient's refusal of medical treatment cannot pose a threat to the community. Communicable diseases, for instance, would require treatment or isolation to prevent the spread to the general public. A mentally ill patient who poses a physical threat to himself or others is another example.
What is the best way for a patient to indicate the right to refuse treatment?
Advance Directives. The best way for a patient to indicate the right to refuse treatment is to have an advance directive, also known as a living will. Most patients who have had any treatments at a hospital have an advance directive or living will.
How to refuse treatment?
The best way for a patient to indicate the right to refuse treatment is to have an advance directive, also known as a living will. Most patients who have had any treatments at a hospital have an advance directive or living will.
What is the end of life refusal?
End-of-Life-Care Refusal. Choosing to refuse treatment at the end of life addresses life-extending or life-saving treatment. The 1991 passage of the federal Patient Self-Determination Act (PSDA) guaranteed that Americans could choose to refuse life-sustaining treatment at the end of life. 9 .
What must a physician do before a course of treatment?
Before a physician can begin any course of treatment, the physician must make the patient aware of what he plans to do . For any course of treatment that is above routine medical procedures, the physician must disclose as much information as possible so you may make an informed decision about your care.
What is the mandate of PSDA?
The PSDA also mandated that nursing homes, home health agencies, and HMOs were required by federal law to provide patients with information regarding advance directives, including do not resuscitate (DNR) orders, living wills, physician’s orders for life-sustaining treatment (POLST), and other discussions and documents.
What is a threat to the community?
A threat to the community: A patient's refusal of medical treatment cannot pose a threat to the community. Communicable diseases, for instance, would require treatment or isolation to prevent the spread to the general public. A mentally ill patient who poses a physical threat to himself or others is another example.
What is Martindale Nolo?
Nolo is a part of the Martindale Nolo network, which has been matching clients with attorneys for 100+ years.
What is considered negligent in medical malpractice?
However, in medical malpractice cases, most courts define negligence as a health care professional's failure to provide treatment that meets the applicable medical standard of care under the circumstances.
What is negligence in personal injury?
In personal injury law, negligence means the failure to exercise the proper amount of care under what lawyers call the "reasonable person" standard. To simplify, if a reasonable person would have taken a certain action, then not taking that action would be considered negligent. Alternatively, if a reasonable person would not have done a certain thing, then doing it would be considered negligent.
What happens if a health care professional is not a standard of care?
A health care professional's deviation from the "standard of care" can lead to a medical malpractice lawsuit.
What is medical malpractice?
A medical malpractice case can be based on a health care provider's act, or failure to act, but the question that must be answered is whether or not the provider's conduct amounted to medical negligence. In personal injury law, negligence means the failure to exercise the proper amount of care under what lawyers call the "reasonable person" ...
What is the standard of care?
Different states define it in slightly different ways, but the medical "standard of care" usually means the degree of care and skill of the average health care provider who practices in the provider's specialty, taking into account the medical knowledge that is available in the field. So, the standard of care is typically based on ...
What is the second school of thought?
Other states use what is called the "second school of thought" or the "respectable minority" definition, in which doctors and lawyers recognize that there may be more than one acceptable method of delivering care to a patient in a given situation.
Why do parents keep their children from getting medical treatment?
Religion is only one of several reasons that parents may use for keeping their child from undergoing a medical treatment. Safety concerns and personal preferences also come into play.
When a parent's beliefs about medicine become child abuse?
When a Parent’s Beliefs About Medicine Become Child Abuse. Parents have a lot of leeway in deciding what medical care their child receives, but sometimes refusing care for their child tips over into neglect. An Oregon couple who believed in faith hea ling were sentenced to six years in prison earlier this month for criminal charges related to ...
What does Bottoms think about treatment?
Bottoms thinks that it depends on what treatment is being refused.
Can doctors convince parents to allow a conventional medical treatment for their child alongside prayer or alternative medicine?
Caplan says that sometimes doctors can convince parents to allow a conventional medical treatment for their child alongside prayer or alternative medicine.
Is the current medical system in many states perfect?
Parasidis admits that the current system in many states isn’t “perfect,” but he thinks it’s better than an outright ban on religious exemptions for medical care.
Can adults refuse medical care?
In the United States, adults can refuse any medical care, as long as they’re competent to make their own decisions. But it gets complicated when parents deny treatment for their children, especially when religion is involved.
Is religious based medical neglect a form of child abuse?
The number of religious-related medical neglect cases is small compared to other types of child abuse and neglect in the country, but child advocates are still concerned. “Faith-based medical neglect is the only kind of child abuse and neglect that’s actually protected by law in many states,” said Rita Swan, co-founder of ...
