The Diagnosis. Russell La Forte, M.D. Area Medical Director Internal Medicine. The Diagnosis. Two Meanings Diagnosis = Patient’s Disease Diagnosis = The artful process by which the patient’s problem is uncovered. The Diagnosis. Neither of these is what “coders” mean by “diagnosis”.
Russell La Forte, M.D.
Area Medical Director
The right answer to the problem
Can be difficult to tie to the patient’s problem
Is often never made or even sought
The “working” diagnosis
Conveys the current level of uncertainty
Suggests what work-up will lead to “the diagnosis”What’s the difference
Less vague – complaint based
Syndrome - usual system specific
Lab based – often organ specific
Abdominal Pain, Rash
Elevated liver enzymesWorking Dx - Uncertainty
Often patients without firm diagnoses present with some change in their symptoms
May or may not be the same disease
Irritable Bowel Syndrome – now complains of blood in stool
Symptom not part of the Syndrome of IBS
Further study indicatedNew symptoms
Body or Mind?
All symptoms are in the patient’s mind – the disease may or may not be