Why Should I Document a Differential Diagnosis?

Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient’s symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.

Courts view the formulation and documentation of a differential diagnosis as evidence of a physician’s competence, prudence, and thoughtfulness.

Results of an Audit: a Case Study

Here at ChiroCode we often get to look at doctor records and provide advice on ways to improve them. One of the main issues is lack of functional progress to establish medical necessity. That may sound like a mouthful, but it is not hard to make sure it is clear in a typical note. Learn about an actual case that was documented well, but still had room for improvement.